Failure to Maintain Complete Abuse Investigation Documentation
Penalty
Summary
The facility failed to maintain complete documentation of an abuse allegation investigation involving a resident with dementia, Parkinson's disease, and delusional disorder. According to the facility's abuse prevention policy, all witness statements should be obtained in writing, signed, and dated, and the results of the investigation should be recorded on approved forms and provided to the Administrator. However, the investigation file for the incident included only one written statement from the Unit Manager, which was based on information reported by a staff member, and a handwritten, undated, and unsigned statement later identified as the resident's. There were no written or signed statements from the staff member who reported the abuse or from other staff present during the shift when the alleged abuse occurred. Interviews with the Assistant Director of Nursing (ADON) and the Administrator confirmed that the required staff statements were not obtained or maintained in the investigation file. The ADON acknowledged responsibility for conducting abuse investigations and stated that she should have collected statements from all staff involved, including the reporter, but was unable to locate them and had only begun to contact staff for statements after the deficiency was identified. The Administrator also confirmed that the investigation documentation was incomplete and that no further information was available regarding the abuse investigation.