Failure to Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility failed to provide documentation that allegations of abuse were thoroughly investigated for one resident who reported being mistreated by staff during activities of daily living (ADL) care. Specifically, a resident alleged to the social worker that a geriatric nursing assistant (GNA) pushed their head on the bed and that some nurses were rough during treatment, causing distress. The facility's documentation included a written statement from the social worker and a statement from one staff member, but lacked resident interviews or staff interviews regarding the care provided by the second staff member implicated in the allegation. Further review revealed that three other residents expressed concerns about the same staff member's treatment, describing her as rough, impatient, and displaying anger towards residents. Despite these concerns, the Director of Nursing (DON) was unaware of the residents' feedback, and the Nursing Home Administrator (NHA) acknowledged that the investigation focused solely on one staff member, overlooking the need to investigate the second staff member's conduct. The lack of comprehensive interviews and follow-up resulted in an incomplete investigation of the abuse allegations.