Failure to Thoroughly Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident admitted for a 5-day respite stay with diagnoses including Alzheimer's disease, dementia, and anxiety disorder. On the evening of the incident, the resident became agitated and attempted to leave the facility through multiple exits. Staff responded by holding doors shut and physically restraining the resident in a chair to prevent elopement. A crisis report and police report documented that staff held the resident in a chair and that the resident later stated to police that they had been attacked by numerous individuals. The facility did not ensure that all staff involved in the incident were interviewed as part of the investigation. Several staff members who were present or directly involved, including CNAs and an LPN, were not asked for statements by facility administration. Some staff indicated they were not approached for statements by the facility, and their accounts were not included in the facility's investigation documentation. Additionally, the facility did not obtain or review the police report or county crisis documentation, both of which contained relevant information about the incident and the resident's allegations. The facility's policy required that all allegations of abuse be thoroughly investigated, including interviewing all witnesses and reviewing all events leading up to the incident. However, the investigation was incomplete, as key staff interviews were not conducted, and external reports were not obtained or reviewed. This failure to follow policy resulted in an incomplete investigation of the abuse allegation involving the resident.