Failure to Thoroughly Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate and report an allegation of abuse as required by policy and regulation. A resident with a history of bipolar disorder, antisocial personality disorder, kidney disease, and diabetes, who was moderately cognitively impaired and had an activated power of attorney, reported to hospital staff that a nurse at the facility had thrown him on the bed. The hospital care coordinator communicated this concern to the Nursing Home Administrator (NHA), who stated she would follow up and report back. The NHA spoke with the nurse and CNA who were working with the resident on the night in question, and their statements matched. The NHA also spoke with the resident, who did not recall the incident and expressed feeling safe at the facility. However, the NHA did not conduct further investigation, such as interviewing other residents or staff. The NHA acknowledged that the resident's statement could be considered an allegation of abuse and should have been thoroughly investigated, but this was not completed.