Failure to Investigate Abuse Allegations and Protect Residents
Penalty
Summary
The facility failed to thoroughly and immediately investigate allegations of abuse and potential theft, and did not prevent further potential abuse or neglect by allowing staff to continue direct care with residents after allegations were made. In one case, a resident with dementia and a history of behavioral issues reported being physically mistreated by a CNA, who was also the administrator's son. Multiple staff members were aware of the incident, which involved the CNA allegedly grabbing, squeezing, and pinching the resident, removing her wheelchair, and shutting her in her room. The resident was left upset and without her wheelchair, and staff reported hearing her call for help. The CNA admitted to being frustrated and taking the wheelchair, and other staff confirmed the resident was visibly distressed. Despite these reports, the administrator did not initiate an immediate or thorough investigation, and the CNA was not removed from resident care until later. The administrator also failed to ensure all staff involved were interviewed promptly, and there was confusion and delay in reporting the incident to authorities. In another instance, a resident reported $200 missing from his room, which he had kept in a cup on his bedside table. The administrator acknowledged being told about the missing money but did not conduct a formal investigation, did not document interviews or findings, and did not report the incident to the state health department as required. Staff were aware of the missing money, but there was no paper trail or evidence of a thorough inquiry. The only documentation was a grievance form stating the resident had no money, with no further follow-up or investigation recorded. Facility policy requires immediate reporting and investigation of all allegations of abuse, neglect, or misappropriation of property, and mandates that accused employees be removed from resident contact during investigations. However, in both cases, these procedures were not followed. The facility did not ensure prompt and complete investigations, failed to protect residents from further potential harm, and did not maintain adequate documentation of the incidents or the investigative process.