Failure to Thoroughly Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving one resident. According to the facility's policy, an immediate and comprehensive investigation is required when abuse is suspected or reported, including identifying responsible staff, preserving evidence, interviewing all involved parties and witnesses, and documenting the investigation in detail. In this case, a nurse reported witnessing a certified nurse aide (CNA) and a resident pulling a tray back and forth, with the CNA allegedly yelling at the resident to leave the dining room. The CNA acknowledged the interaction but denied any inappropriate behavior or yelling. The investigation documentation only included statements from the reporting nurse and the CNA involved. There were no interviews conducted with other staff members or residents who may have had relevant information or prior experience with the CNA. The Director of Nursing, who conducted the investigation, could not provide documentation of any additional interviews. The Chief Nursing Officer confirmed that no further interviews were available and acknowledged that additional interviews should have been conducted and documented as part of the investigation.