Failure to Complete Thorough Abuse and Neglect Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of staff-to-resident verbal abuse and neglect involving two residents. Specifically, the facility did not complete resident monitoring, did not implement interventions that were identified and documented in the incident reports, and did not interview other residents to determine if additional individuals were affected. Documentation for several incidents was incomplete, lacking summaries, evidence of staff education, and records of monitoring activities such as bathing logs or audits. Interviews with staff revealed that investigation folders had not been fully reviewed and that the investigations were still in progress, despite being part of a plan of correction from a previous complaint survey. The facility's own policy requires comprehensive investigation procedures, including reporting, analysis, staff training, and monitoring, but these steps were not documented or carried out as required for the incidents in question.