Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into multiple incidents of potential resident-to-resident abuse, as required by its own policy on the prevention of abuse, neglect, mistreatment, or misappropriation of property. In several cases, the investigations did not include interviews with all residents involved or potentially affected, nor did they consistently gather statements from all relevant staff or witnesses. For example, in an incident involving two residents observed kissing, the investigation was limited to notifying responsible parties and providing staff education, but did not include interviews with the residents involved. In another incident, a resident with severe dementia made contact with another cognitively impaired resident using a plastic utensil, resulting in a skin tear. Although the incident was reported to the governing agency, the investigation did not include interviews with the residents involved. Similarly, in a case where a resident was observed placing his hand on another resident's upper thigh, the investigation only included statements from the alleged perpetrator, a staff witness, and several CNAs, but did not include interviews with other residents to determine if they felt safe or had experienced similar incidents. Additionally, in a case of alleged inappropriate verbal comments and boundary violations, the investigation was limited to interviews with the two residents directly involved, one CNA, and the maintenance director, with no further inquiry into whether other residents or staff had observed similar behavior or felt at risk. Interviews with the facility administrator revealed a lack of awareness regarding the need to interview all potentially affected residents and staff during abuse investigations, contributing to incomplete investigative processes.