Failure to Thoroughly Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident who reported that his roommate had fondled his leg and groin. The resident, who had diagnoses including high blood pressure, malnutrition, and low back pain, was visibly shaken and expressed fear following the incident. Documentation indicated that the resident had previously reported similar concerns, but felt that no action had been taken. The facility's policy required all allegations of abuse to be thoroughly investigated and documented, including obtaining written, signed, and dated witness statements. Upon review, it was found that the investigation file lacked a written statement from the nurse aide who first responded to the incident, and there was no documentation clarifying the licensed practical nurse's knowledge of any prior sexual abuse allegations. Although the DON stated that a detailed interview was conducted with the LPN regarding prior knowledge, this interview was not documented. The DON confirmed that the facility did not conduct a thorough investigation as required by policy.