Failure to Assess Cognitively Impaired Residents During Abuse Investigations
Penalty
Summary
The facility failed to ensure a thorough investigation was completed for allegations of abuse involving multiple residents. In one incident, a resident reported that two nursing assistants entered the room, physically assaulted the resident, and broke the resident's phone. While the facility's investigation included law enforcement notification and statements from the resident, alleged perpetrators, staff, and cognitively intact residents, it did not include assessments of cognitively impaired residents who were assigned to the alleged perpetrators. In another incident, a registered nurse observed one resident hitting another on the head with an object. The facility obtained staff statements and notified law enforcement but did not interview or assess other residents who may have interacted with the alleged perpetrator. In a third case, a resident reported being slapped and restrained by a GNA during care. The investigation again included law enforcement notification and statements from relevant parties, but failed to assess cognitively impaired residents assigned to the alleged perpetrator. The Director of Nursing acknowledged that cognitively impaired residents had not been included in these investigations.