Failure to Thoroughly Investigate Abuse Allegations and Protect Residents
Penalty
Summary
The facility failed to provide evidence that allegations of abuse were thoroughly investigated for four residents and did not implement interventions to prevent further potential abuse or neglect for one resident while an investigation was in progress. Facility policy required all allegations of abuse, neglect, exploitation, or misappropriation to be thoroughly investigated, with specific steps including interviews with all relevant parties, documentation, and protection of residents and reporters from retaliation. However, in multiple cases, the facility did not document interviews with other residents or staff who may have been affected or had contact with the accused employee, nor did they always assess residents for injury following allegations. For one resident with moderate cognitive impairment and on anticoagulant therapy, an allegation was made that a CNA was rough during care, resulting in bruising. While the accused CNA was suspended and some interviews were conducted, there was no documented evidence that other residents cared for by the CNA were interviewed or assessed. In another case, a resident with intact cognition alleged that a CNA kicked their leg and had inappropriate interactions with their roommate, who had severe cognitive impairment. The investigation did not include documented interviews or statements from other staff, family members, or other residents, nor was there documentation of injury assessments for the involved residents. In a third case, a resident with a history of blood clots and on anticoagulant therapy alleged that a physical therapist caused harm during treatment, leading to hospitalization. The facility did not suspend the therapist during the investigation and did not document any steps taken to protect other residents or to interview them about their experiences with the therapist. Across all cases, the facility's failure to follow its own investigative procedures and to document thorough investigations led to the deficiency.