Failure to Thoroughly Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident physical and verbal abuse involving one resident with severe cognitive impairment. The incident involved a resident with a history of type two diabetes mellitus, cirrhosis of the liver, and aphasia, who was admitted with a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. The resident was known to refuse care and exhibit combative behaviors. On the date of the incident, a CNA reported that an LPN called the resident derogatory names and struck the resident on the hand and face during care. The CNA did not intervene at the time, stating she was in shock, and delayed reporting the incident until after the LPN had left the building. The facility's investigation included statements from the involved staff, assessment by the Medical Director, and notification of the police, who found no evidence of criminal activity. The resident was assessed and found to have no injuries, and interviews with other cognitively intact residents assigned to the LPN revealed no concerns. However, the investigation did not include assessment of other cognitively impaired residents under the LPN's care for possible signs of abuse. The facility unsubstantiated the allegation based on the lack of physical evidence and the LPN's history, and the LPN was allowed to return to work after a suspension. Despite the steps taken, the facility's investigation was incomplete as it failed to assess all potentially affected residents, particularly those with cognitive impairment who may not be able to report abuse. The deficiency was further highlighted by the fact that the CNA did not intervene or immediately report the incident, and the facility did not ensure that all residents were protected from potential harm during and after the investigation, as required by their own policy.