Failure to Document Complete Abuse Investigation
Penalty
Summary
The facility failed to maintain an accurately documented and complete investigation in accordance with accepted professional standards following an allegation of abuse made by a resident. The incident involved a resident with severe cognitive impairment, as indicated by a BIMS score of 5, and multiple neurological diagnoses including cerebral infarction, hemiplegia, and hemiparesis. The resident alleged that someone had raped them, describing the perpetrator as a short black male wearing tan, seen outside the window of their second-floor room. The facility's initial investigation included a review of the visitor log and staff schedule, which did not match the description, and a physical assessment of the resident. However, the investigation documentation submitted to the surveyor did not include any witness statements at the time of review. Interviews with facility leadership confirmed that obtaining witness statements is a required part of the abuse investigation process, as outlined in facility policy and training materials. Despite this, no witness statements were provided to the surveyor during the initial documentation request. The Assistant LNHA acknowledged that witness statements are essential and indicated they would continue searching for them. The surveyor did not receive any additional documentation, including witness statements, before exiting the facility. The absence of these statements constituted a failure to follow established investigative procedures for abuse allegations.