Failure to Properly Investigate Alleged Abuse and Identify Involved Staff
Penalty
Summary
The facility failed to follow its own policy for conducting a thorough investigation of alleged abuse, specifically by not properly identifying the staff involved in an incident reported by a resident. The resident, who had multiple diagnoses including major depressive disorder, morbid obesity, and chronic obstructive pulmonary disease, reported that two CNAs entered his room and one made a derogatory and abusive remark. Initial investigation led to the suspension of the wrong CNA due to misidentification, and only after further interviews and review of schedules were the correct staff members identified. The confusion over which staff were involved was compounded by inconsistent statements and uncertainty from both the resident and facility leadership. The resident described feeling fearful of retaliation from one of the CNAs involved, particularly after observing her continue to work on his hall and walk past his room, sometimes laughing. The resident reported that after the incident, he was left without assistance to use the bathroom for an extended period and that the staff involved did not respond to his needs. Interviews with other staff and residents revealed varying accounts, with some staff denying knowledge of the incident and others reporting that the resident had used inappropriate language toward the CNAs. The administrator admitted to confusion and panic during the investigation process, acknowledging that the wrong CNA may have been suspended initially and that the timeline of the incident was unclear. The facility's own abuse prevention and investigation policy required immediate reporting and a thorough investigation of alleged violations of residents' rights. However, the investigation was hampered by misidentification of staff, inconsistent documentation, and uncertainty about the sequence of events. The resident did not have a care plan addressing abuse, and the administrator expressed uncertainty about the details of the incident and the actions taken. This failure to properly identify the alleged staff involved and to conduct a clear, thorough investigation resulted in the resident experiencing ongoing fear of retaliation.