Failure to Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse for two residents. In the first case, a resident with multiple diagnoses including dementia, Huntington's disease, and repeated falls, experienced a witnessed fall. The facility determined that abuse had occurred based on a progress note from an LPN. However, the investigation was incomplete as it did not include statements from the involved CNA or LPN. Additionally, the staff education provided after the incident was inaccurate, as it did not reflect the resident's care plan requirements for transfer assistance, and only a fraction of employees signed the education documentation. In the second case, another resident with intact cognition and a history of falls and other medical conditions reported that a CNA was abusive, describing being manhandled and treated rudely during care. The grievance was documented, but the investigation did not follow facility policy, as it lacked immediate action, root cause analysis, interviews with other potentially affected residents, and witness statements from involved staff. There was also no documentation of staff education signatures or further investigative records related to this allegation. Both incidents demonstrate that the facility did not adhere to its own policies regarding the immediate and thorough investigation of abuse allegations. Required investigative steps, such as obtaining statements from all involved parties and ensuring accurate staff education, were not completed, resulting in deficiencies in the facility's response to reported abuse.