Failure to Conduct Comprehensive Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with intact cognition who reported that a Geriatric Nurse Assistant (GNA) forcibly took tea bags from their hands, resulting in increased pain and weakness in the resident's wrists and arms. The incident was witnessed by another GNA, who described a tugging motion between the staff member and the resident. The resident later reported a pain level of 9 out of 10 and ongoing weakness and tingling in the affected areas. Medical records confirmed the resident was cognitively intact at the time of the incident. During the investigation, the facility interviewed other residents assigned to the alleged staff member, with seven residents denying any abusive encounters. However, the facility did not conduct skin assessments or body checks for four cognitively impaired, non-verbal residents who were also under the care of the alleged perpetrator. Both the DON and the Nursing Home Administrator confirmed that body checks for non-verbal or vulnerable residents were expected as part of the abuse investigation process, but these assessments were not performed.