Failure to Include Key Witness Interview in Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident physical abuse involving a resident who reported being slapped, choked, and having her hands squeezed by a caregiver. The resident, who had moderately impaired cognition, stated that her roommate was present during the alleged incident and reported the event to facility staff. The facility's policy requires immediate investigation of abuse allegations, including interviewing all involved individuals and potential witnesses. During the investigation, the facility staff responsible for conducting witness interviews did not provide the Abuse Coordinator with the interview conducted with the resident's roommate, who was identified as a potential witness. The roommate, also with moderately impaired cognition, stated she did not see the abuse due to poor vision but heard the resident yelling about being hit. The interview with the roommate was conducted by the Social Services Assistant (SSA), but the documentation was not included in the investigation file and was instead placed in the facility's shred box by the Social Services Director (SSD) after being told by the MDS Coordinator that the roommate had no capacity to be interviewed. The Administrator, who served as the Abuse Coordinator, confirmed that the interview with the roommate should have been included in the investigation, as per facility policy. The omission of this interview meant that not all potential witness information was available to determine whether abuse occurred, and the facility's investigation was incomplete as a result.