Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into an allegation of resident abuse. A resident with intact cognition and multiple medical diagnoses, including depression and an abscess requiring wound care, reported being struck on the hand by an LPN during a wound care procedure. The resident stated she attempted to assist by holding her abdominal fold, after which the LPN allegedly slapped her hand and yelled at her not to touch the area. The resident reported the incident to the administrator the following day. Another resident, who was the roommate and present in the room at the time, confirmed hearing the incident and the LPN's verbal response, although she did not visually witness the event due to a privacy curtain. The facility's investigation into the incident was incomplete. While the facility submitted a Self-Reported Incident (SRI) and interviewed the accused LPN, they failed to obtain a witness statement from the roommate who was present and did not collect statements from any other staff. The facility's own policy requires that all witnesses, including those who heard or were in close contact with the incident, be interviewed as part of the investigation. The Director of Nursing confirmed that these steps were not taken, resulting in a deficient investigation process.