Failure to Conduct Thorough Abuse Investigation and Adhere to Care Plan
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of an allegation of abuse involving a resident with complex medical conditions, including muscle weakness, difficulty walking, and right foot drop. The resident, who was dependent on staff for bed mobility and transfers, reported experiencing pain during a transfer when only one staff member assisted, contrary to the care plan requiring two-person assistance with a mechanical lift. The resident described being handled roughly and yelled at by the staff member during the incident, which was witnessed by a family member present in the room. A collateral contact also reported hearing the resident scream and noted that they had never observed two staff assisting the resident, despite frequent visits. The facility's investigation into the incident was incomplete. Although the investigation included interviews with the resident, a collateral contact, the staff member involved, other residents, and staff, there was no documentation of an interview with the family member who witnessed the event. Additionally, the investigation did not include a statement from the LPN assigned to the unit at the time of the incident. The staff interviews that were conducted were unsigned, undated, and mostly lacked staff titles, and the questions asked did not address the specifics of the incident or the staff member's conduct during the event. Furthermore, the investigation did not address why the staff member failed to follow the resident's care plan requiring two-person assistance, nor did it explore whether this practice was common among other staff or shifts. There was also no documentation that the facility inquired about the staff member's treatment of other residents or any observations of yelling. These omissions resulted in a lack of evidence demonstrating a thorough investigation as required by facility guidelines.