Failure to Conduct Accurate Investigations of Abuse Allegations
Penalty
Summary
Facility staff failed to conduct accurate and thorough investigations into allegations of inappropriate touching between two residents. In the first incident, a resident reported that another resident touched her thigh in the hallway while she was writing a letter. The administrator, who was present at the time of the report, dismissed the possibility of the incident based on her own observations of the physical setup and the alleged perpetrator's routine. The investigation lacked written witness statements from both the staff member who reported the incident and the residents involved, as required by facility policy. In a second incident, the same resident reported being inappropriately touched by the same alleged perpetrator while in the weight room. Staff immediately separated the residents and provided follow-up care, including psychological services and changes to room assignments to ensure safety. However, the investigation into this incident was also incomplete. It did not include statements from the residents involved or from a Certified Nursing Assistant who witnessed the event, although the CNA's statement was later provided. Additionally, the investigation inaccurately documented the details of the incident and omitted relevant information from the nurse practitioner who followed up with the resident. Facility documentation reviews revealed that the required procedures for investigating abuse allegations were not followed. The facility's policies mandate obtaining written statements from all involved parties and witnesses, as well as accurate and detailed reporting of the events. In both incidents, these requirements were not met, resulting in incomplete and inaccurate investigations of the alleged violations.