Failure to Conduct Thorough Investigations of Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse and misappropriation of property for two residents. For one resident with multiple psychiatric and medical diagnoses, documentation showed that the resident reported a missing wallet containing important identification cards following a hospital stay. Although the resident did not suspect theft or want police involvement, there was no evidence that the facility conducted or documented interviews with staff, the resident, or other potential witnesses. Additionally, when requested, the facility was unable to provide a five-day investigation report or related grievance logs, and the administrator confirmed that such documentation was not available. For another resident with dementia and a history of falls, the facility reported a witnessed fall that resulted in a hip fracture. The clinical record indicated a change in the resident's condition prior to the fall, and a physician's note later stated the injury was due to a resident-to-resident altercation. However, there was no documentation in the clinical record to support the occurrence of an altercation, and required interviews with staff and residents were not completed. Attempts to interview staff were unsuccessful due to lack of recollection or staff no longer being employed. Facility policies required comprehensive investigations of all incidents, including interviews with witnesses, staff, and residents, as well as detailed documentation of the circumstances and follow-up. In both cases, the facility did not follow its own policies and procedures for investigating and documenting incidents of potential abuse, misappropriation, or altercations, resulting in incomplete investigations and insufficient records.