Failure to Conduct Thorough Investigations of Abuse Allegations and Drug Use
Penalty
Summary
The facility failed to ensure a complete and thorough investigation of allegations of abuse and unusual events for two residents. In the first instance, a resident with Alzheimer's disease, dementia, anxiety, and depression was involved in a resident-to-resident altercation where three other residents were reportedly touched inappropriately. The facility's investigation listed three staff members as witnesses, but their written witness statements were missing from the investigation file. The DON was unable to locate these statements, and interviews with the staff revealed that at least one did not recall providing a statement, while another reported verbally to the DON. The facility's policy required written and signed witness statements, which were not present in this case. In the second instance, a resident with a history of traumatic brain injury, epilepsy, dementia, and substance abuse tested positive for marijuana and methamphetamine after being sent to the emergency room for seizure-like activity. The resident's room had been reported to have a chemical and marijuana smell, and a search of the roommate's belongings uncovered multiple prohibited items, including vape devices, glass smoking devices, and THC-a smoking material. Despite these findings and the positive drug test, there was no documented investigation into the source of the drugs, nor was a facility reported incident (FRI) submitted to the state agency or notifications made to other required agencies regarding the drug use. The administrator confirmed that no FRI was initiated for the positive drug test and that the investigation focused solely on the roommate's aggressive behaviors, not the drug incident. The facility's policy required all alleged violations involving abuse, neglect, exploitation, or injuries of unknown source to be thoroughly investigated and reported to appropriate agencies, but this was not done in the case of the resident's positive drug test. No documentation of a formal investigation into the drug incident was provided prior to the survey exit.