Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into multiple alleged abuse incidents involving several residents. In each case, the documentation showed that only one staff interview was conducted, with no resident interviews or evidence of ongoing monitoring after the incidents. Specific events included a resident-to-resident physical altercation in a shared room, a confrontation in the dining room where one resident struck another with a clothing protector, and a verbal altercation in a resident's room. In all instances, the facility's investigation records were incomplete, lacking interviews with all involved parties and failing to document follow-up actions or monitoring. Interviews with staff revealed that while some believed additional interviews had been conducted, they were unable to locate the relevant documentation. Key staff members responsible for the investigations were no longer employed at the facility, and the available records did not meet the requirements outlined in the facility's abuse investigation policies. These policies required immediate and comprehensive investigations, including interviews with all involved individuals and thorough documentation, which were not followed in these cases.