Failure to Thoroughly Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations were thoroughly investigated for two residents with dementia who were involved in an incident of possible abuse. The incident involved one resident being found on her knees next to her roommate's bed, with her pants down and her hand in the area of the other resident's buttocks. The eyewitness, an LPN, reported observing the resident placing her finger near the roommate's rectum and immediately intervened. The roommate was non-communicative and unable to provide a statement due to severe dementia. The incident was reported to management, police, and family members, and both residents were separated and monitored. Despite the eyewitness account and the police report describing digital manipulation of the roommate's vagina and anus, the facility's internal investigation concluded that nothing inappropriate had occurred. The investigation relied heavily on the resident's history as a former CNA and her confused statements, as well as the lack of physical injuries or behavioral changes in the roommate. The facility did not document any findings that addressed the eyewitness's detailed account or the police report, nor did they provide documentation of steps taken to address the specific alleged violation. Nurses' notes for the roommate did not mention the incident, and interviews with staff indicated a lack of clarity about the nature of the incident and the actions taken. The facility's abuse policy outlines steps for investigating alleged incidents, including reviewing documentation, interviewing witnesses, and assessing residents. However, the investigation in this case did not address key evidence, such as the eyewitness's statement and the police report, and failed to document a thorough review of the incident. The lack of comprehensive documentation and failure to address all aspects of the allegation resulted in a deficiency related to the facility's responsibility to thoroughly investigate and respond to alleged violations.