Failure to Conduct Thorough Investigations of Abuse, Neglect, and Misappropriation Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse, neglect, and misappropriation involving three residents. In one case, a resident with depression, anxiety, cognitive communication deficit, and dementia reported $353 missing. The facility's investigation included interviews with other residents but did not include any staff interviews, contrary to facility policy. The administrator confirmed that staff were not interviewed and acknowledged the investigation was not thorough. In another instance, a cognitively intact resident involved in an altercation with another resident was not assessed, and vital signs were not obtained. The investigation contained conflicting witness statements, and a key witness, the therapist who initially reported the incident, was not interviewed. In a third case, a resident reported missing personal items, including a wallet and $500. The investigation did not confirm if all staff were interviewed due to uncertainty about when the items went missing, and there was no personal inventory to verify ownership of the wallet. The administrator confirmed the investigation was incomplete. Facility policy required interviews with all relevant parties, but this was not consistently followed.