Failure to Interview Key Individuals in Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving one resident. According to the facility's own policy, all persons involved in an alleged abuse incident, including the alleged victim and perpetrator, must be interviewed as part of the investigation. However, when a resident's representative reported that the resident was found tied to a wheelchair with a bedsheet and alleged that a CNA had hit and kicked him, the facility did not conduct or document interviews with either the resident or the CNA involved. The investigation documentation showed that the facility interviewed the resident's family member, assessed the resident for injuries, and interviewed staff from the relevant shift and those who had provided care in the preceding 72 hours. Despite these steps, there was no evidence that the resident (the alleged victim) was interviewed directly, nor was there documentation of an interview with the CNA (the alleged perpetrator). The DON acknowledged that a written statement from the CNA was obtained, but this was not equivalent to an interview, and no documentation was provided to confirm an interview with the resident. The resident involved had moderate cognitive impairment and required maximum staff assistance for activities of daily living, but was determined to have the capacity to understand and make decisions. The failure to interview both the alleged victim and perpetrator was contrary to the facility's policy and left the investigation incomplete, as key firsthand accounts were not obtained or documented.