Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with multiple complex medical conditions, including acute kidney failure, hydroureter, obstructive and reflux uropathy, and a history of prostate cancer. The resident, who had moderate cognitive impairment, was reported by his family member to have experienced rough handling by a male staff member while being provided with dry blankets, which allegedly resulted in the pulling of a tube and subsequent transfer to an acute care hospital. The administrator, who served as the abuse coordinator, interviewed the involved staff and the resident, but concluded the incident occurred at another hospital based on her interview with the resident, despite the family member's clarification that the event took place at the facility. The administrator obtained written statements from the staff involved and interviewed the resident at the hospital, but did not pursue further investigation after her initial conclusion. The family member had specifically reported the incident as occurring at the facility, and the staff member identified as being involved confirmed familiarity with the resident and described care provided during the relevant shift. The lack of a comprehensive investigation into the abuse allegation constituted a failure to respond appropriately to the reported violation.