Failure to Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident abuse involving one resident. The resident, who had intact cognition and was their own decision maker, reported that during transportation to a physician appointment, two staff members argued, yelled at each other using vulgar language, and then yelled at the resident in a threatening manner not to disclose the incident. The resident reported feeling uncomfortable and informed facility staff of the incident. However, there was no evidence in the facility's grievance file of an investigation into the allegation, and the Director of Nursing confirmed that while the incident was reported to the former Nursing Home Administrator, there was no further information or documentation regarding an investigation. Upon review, the current Nursing Home Administrator acknowledged that an investigation should have been initiated after the resident's report, and that the involved staff should have been suspended pending the outcome. The facility's own policy required immediate and thorough investigation of abuse allegations, including interviews and documentation, but these steps were not followed. The lack of investigation and documentation constituted a failure to respond appropriately to the reported abuse allegation.