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 two residents reviewed for abuse and neglect. In the first case, a family member alleged neglect after observing a resident in a soiled brief. The facility's investigation did not include a physical assessment of the resident due to her discharge status and only included resident and staff interviews from other units, not the unit where the resident resided. The administrator confirmed that residents on the relevant unit were not surveyed during the investigation, and the determination of safety was based on routine staff rounds rather than direct investigation of the specific unit involved. In the second case, a family member alleged that a resident had been physically assaulted, resulting in a facial injury. The investigation included a physical assessment of the resident, interviews with the resident and family, and review of video footage. However, the investigation did not include abuse or neglect surveys of residents in the memory care unit where the resident lived, as the administrator believed those residents could not participate due to cognitive decline. No physical assessments were performed in place of verbal surveys for these residents, and the administrator relied on staff interviews and routine rounds to determine safety. Facility policy required investigations to include observations of the alleged victim, monitoring of at-risk residents, and assessment of interactions between staff and residents. Despite this, the investigations for both residents did not include direct interviews or assessments of other residents in the same units as the alleged victims. Additionally, some resident interview questionnaires were provided after the survey exit, without documentation of room numbers, making it impossible for surveyors to verify their relevance to the cases.