Failure to Interview All Relevant Staff During Abuse Investigations
Penalty
Summary
Facility staff failed to conduct thorough investigations into two separate facility-reported incidents involving allegations of abuse. In both cases, the investigations did not include statements from all staff members who were present during the shifts when the alleged incidents occurred. Specifically, for one incident involving a resident, the staffing sheet indicated that four Geriatric Nursing Assistants (GNAs) and one nurse were present during the relevant shift, but their statements were not included in the investigation file. Instead, statements were collected from other staff not listed on the assignment sheet. The Assistant Nursing Home Administrator explained that statements are taken on a case-by-case basis, often relying on clinical rationale and summarizations rather than comprehensive staff interviews. In a second incident involving another resident, the investigation similarly lacked statements from the assigned LPN and a GNA who were present during the time of the alleged abuse. The surveyor confirmed with the facility administrator that a thorough investigation was not completed because not all staff who worked during the alleged incidents were interviewed. These omissions were identified during a recertification survey and were based on a review of facility records, staffing sheets, and staff interviews.