Failure to Interview All Relevant Staff in Abuse Investigations
Penalty
Summary
The facility failed to interview all individuals identified as involved or with knowledge of alleged abuse incidents for two of seven sampled residents. In the first case, a resident with intact cognition and a history of COPD, anxiety, traumatic brain injury, and asthma reported to the DON that an LPN caused a bruise and swelling to their finger by pulling an inhaler from their hand. The facility's investigation included interviews with the resident, the LPN, and statements from staff who worked with the resident, but did not include a statement from a therapist who was reported to have been told by the resident about the incident. The Speech Language Pathologist later confirmed having a vague recollection of the resident mentioning an incident with a staff member. In the second case, a resident with severe cognitive impairment and a history of dementia, osteoporosis, glaucoma, muscle weakness, and falls was found to have a bruised, swollen, and warm finger, later determined to be fractured with an unknown origin. The facility's investigation did not include statements from the RN or LPN who documented or provided care at the time of the injury. Interviews with facility leadership confirmed that not all staff who worked with the resident within the relevant look-back period were interviewed, contrary to facility policy and expectations.