Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of verbal abuse involving one resident. The incident began when a resident's representative expressed concerns about rough handling and rude behavior by staff during a room transfer. Documentation showed that a grievance was filed and a care conference was held to discuss the concerns, but there was no evidence that the facility initiated or documented an investigation into the alleged verbal abuse. The facility's own policies require that all grievances and allegations of abuse be reviewed and investigated, with findings documented in a timely manner. Interviews with facility leadership confirmed that no investigation was conducted regarding the grievance about staff rudeness, and the current Director of Nursing and Licensed Nursing Home Administrator were unable to explain why, as they were not employed at the facility at the time. The facility's policies on grievances and incident investigations outline specific steps for prompt review and documentation, but these procedures were not followed in this case. The lack of an investigation was confirmed through review of facility records and direct questioning of staff.