Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with multiple complex medical conditions, including chronic obstructive pulmonary disease, severe protein-calorie malnutrition, atrial fibrillation, and cognitive communication deficit. The resident reported feeling mistreated while at the facility, which was communicated to the social worker at the hospital. Upon the resident's return, the administrator interviewed the resident, who then stated he felt safe and did not feel mistreated. However, there was no documentation of a comprehensive investigation into the allegation. Review of facility records and the Self-Reported Incident (SRI) revealed that no further investigative actions were taken. There were no interviews conducted with staff or other residents, and no skin assessments were completed. The facility's policy requires all allegations of abuse, neglect, or mistreatment to be investigated, but in this case, no investigation could be found, and the Regional Director of Clinical Services confirmed the absence of any investigative documentation related to the incident.