Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a female resident with dementia and moderately impaired cognition, who required assistance with activities of daily living and had a sitter present. On the day of the resident's discharge, a sitter was overheard telling EMS personnel that the resident had been abused and that hospice staff were aware. This verbal allegation was reported to the charge nurse and escalated to the Administrator. Despite the report, the Administrator did not interview the resident, her representative, or the caregiver who made the allegation. The Administrator stated that he did not investigate further because the resident had already left the building and was unsure if he had contact information for the sitter. The only interview conducted was with the CNA who overheard the conversation. The DON attempted to call the family member once after the allegation but did not reach them, and no one attempted to contact the caregiver directly. Facility policy requires immediate and thorough investigation of abuse allegations, including identifying and interviewing all involved persons, such as the alleged victim, perpetrator, witnesses, and others with knowledge of the incident. In this case, the investigation was incomplete as key individuals were not interviewed, and the investigation was concluded as unconfirmed without gathering all necessary information.