Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and neglect involving two residents. In the first case, a resident with Alzheimer's disease, depressive disorder, and a femur fracture alleged that a GNA was rough during care, causing bleeding. Although the resident initially refused assessment, a later skin check showed no injury. The facility's internal investigation included interviews with some staff and residents, but did not document whether staff were asked about prior observations of rough or unprofessional behavior by the GNA, nor whether other residents felt unsafe or had experienced similar issues. The investigation was concluded as unsubstantiated without fully determining if other residents were at risk. In the second case, following an allegation of neglect by another resident against a staff member, the facility suspended the alleged perpetrator and interviewed some residents on the staff member's assignment who could communicate. However, the investigation did not include head-to-toe assessments of non-verbal residents who had also been under the care of the alleged perpetrator. The DON acknowledged that these residents, who could not speak for themselves, were not assessed as part of the investigation, resulting in an incomplete review of the potential neglect incident.