Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to identify and investigate an incident of possible abuse involving a resident with dementia, high blood pressure, and anxiety. The incident occurred when the Nursing Home Administrator (NHA), accompanied by a sheriff's deputy, confronted the resident in a public hallway about a significant outstanding balance, repeatedly stating the amount owed and referencing issuing 30-day notices. The resident became visibly distraught, was crying, and expressed confusion about the situation. Witnesses, including staff members, observed the resident's emotional distress and reported the event as potential verbal and psychological abuse. Despite the facility's policy requiring immediate reporting and investigation of all abuse allegations, the incident was not properly addressed. Staff members were instructed to submit written statements, and some did so, but the Director of Nursing (DON) reported receiving no statements. Witnesses later confirmed that they had submitted statements, which were not acknowledged or acted upon. The former NHA gave conflicting accounts regarding whether an investigation was conducted, at first stating that no investigation occurred and later claiming an investigation file existed but could not be located. Multiple staff interviews confirmed that the event was witnessed, statements were submitted, and concerns about abuse were raised. However, the facility did not follow its own procedures for investigating abuse allegations, failed to notify the Department of Health as required, and did not document or analyze the evidence. The NHA ultimately confirmed that the facility failed to identify and investigate the abuse allegation involving the resident.