Failure to Thoroughly Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident verbal abuse involving a resident who was cognitively intact and had multiple chronic medical conditions, including chronic atrial fibrillation, congestive heart failure, and chronic kidney disease. The resident reported that a certified nurse assistant (CNA) was verbally abusive on more than one occasion, describing incidents where the CNA spoke to her in a loud and mean tone. The resident was unable to recall the CNA's name but provided a physical description. The facility's records show that the administrator initiated an investigation, notified the police and physician, and submitted a report to the state health department. However, the investigation was incomplete and lacked critical documentation. The administrator collected 18 staff questionnaires, but only 12 were identified by name, while the remaining 6 were anonymous with no way to determine who provided the information. The administrator admitted to not keeping a list of interviewed staff and could not confirm whether all relevant staff, including those scheduled during the alleged incidents, were interviewed. Several CNAs who worked during the relevant period stated they were not made aware of the allegation, were not interviewed, and did not complete any questionnaires regarding the incident. The facility's abuse prevention policy requires that all interviews be documented with names and contact information, and that all staff participate in investigations. The administrator stated that some staff refused to sign their names and that she could not force them to cooperate. The regional operations director clarified that participation is mandatory and that refusal could result in termination. The investigation file did not meet the facility's policy requirements, as it lacked a complete list of interviewed staff and failed to ensure all relevant staff were questioned and identified.