Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged abuse incident involving a resident with hemiplegia, epilepsy, and chronic obstructive pulmonary disease. On the date of the incident, the resident alleged that a registered nurse held their hands during medication administration, and conflicting accounts were provided by staff and the resident. The facility's policies required a comprehensive review of all events, interviews with all involved parties, and complete documentation, but these steps were not fully carried out. The initial incident report lacked details on who assessed the resident for injuries, and there was no immediate documentation of a head-to-toe assessment or progress note by the unit manager after the event. Multiple staff statements and the resident's account presented inconsistencies regarding the sequence of events and the actions taken by the nurse. The nurse reported being struck by the resident and attempting to restrain the resident's arms, while the resident claimed the nurse tried to force medication and held their hands. A superficial abrasion was later found on the resident's wrist, but the investigation did not resolve the discrepancies in the accounts. The facility's report to the state health department noted several versions of the story and ultimately concluded the findings were inconclusive. When requested, the facility was unable to provide additional documentation or evidence of further interviews to clarify the inconsistencies or to explain why the investigation was inconclusive. Interviews with staff and the resident conducted during the survey revealed lapses in memory and a lack of follow-up questioning after the incident. The facility did not meet its own policy requirements for a thorough and complete investigation of the alleged abuse, as not all involved parties were interviewed and not all events were fully documented.