Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to provide evidence that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for four out of six residents reviewed. Specifically, there were three separate incidents involving resident-to-resident altercations that were not fully investigated according to facility policy and regulatory requirements. In two incidents, one resident was slapped on the neck and later punched on the arm by another resident, and in a third incident, a resident was pushed by another, resulting in a fall. In each case, the facility's investigation did not include documentation that other residents were interviewed to ensure their safety and wellbeing following the allegations. The residents involved had significant cognitive and physical impairments, including diagnoses such as Huntington's disease, bipolar disorder, schizoaffective disorder, dementia, and other mental health conditions. Assessments indicated that these residents had severely to moderately impaired cognition and required varying levels of assistance with daily activities. Despite these vulnerabilities, the facility did not complete or document 'safe surveys' or interviews with other residents who may have been affected or witnessed the incidents, as required by facility policy. Interviews with staff, including the DON, social worker, and administrator, revealed a lack of clarity and follow-through regarding responsibility for conducting and documenting safe surveys after abuse allegations. The DON and administrator acknowledged that the facility's policy required such actions, but stated that these were not completed or documented, particularly when the social worker was unavailable. The facility's own policy outlined the need for comprehensive investigations, including interviews with other residents, but this was not consistently followed or recorded in the cases reviewed.