Failure to Complete Timely Abuse Investigation and Documentation
Penalty
Summary
The facility failed to conduct and complete a thorough investigation within five working days following an allegation of abuse involving a resident who was admitted with cellulitis of the abdominal wall and an ileostomy. The resident reported that a CNA was verbally inappropriate and rude, specifically stating, "You're here because God doesn't like you." Documentation review revealed that there was no investigation summary available for this allegation, and the Infection Preventionist, who also served as the DON designee, confirmed the absence of documentation regarding the findings or results of the investigation. Interviews with facility leadership, including the Administrator, confirmed that the required investigation summary was not completed as per facility policy, which mandates that all abuse allegations be thoroughly investigated and findings reported within five working days. The lack of documentation meant that it could not be determined what actions, if any, were taken during the investigation, nor whether protective interventions or corrective actions were implemented to address the allegation.