Failure to Properly Investigate and Respond to Alleged Resident Abuse
Penalty
Summary
The facility failed to conduct a thorough and accurate investigation into an allegation of abuse involving a cognitively intact resident with Parkinson's Disease, Spinal Stenosis, and Scoliosis, who requires staff assistance for all activities of daily living. On two separate occasions, the resident was heard screaming for help, stating that a CNA was hurting her. The RN on duty responded and observed the CNA at the bedside, with the resident reporting that the CNA had hit her arm and hand multiple times during care, causing immediate pain. The resident consistently described being struck and experiencing distress during interviews. Despite the resident's clear and repeated outcries, the nurse on duty did not provide immediate protection by removing the alleged perpetrator from resident contact, instead attempting to reassign the CNA to a different resident. Only after direct instruction from the DON was the CNA removed from the building. The facility's investigation did not adequately evaluate the resident's distress or reconcile witness statements with the regulatory definition of abuse, which includes the willful infliction of physical pain regardless of injury or malicious intent. The investigation concluded that the allegation was unsubstantiated without properly assessing the credibility of the resident's statements or applying the federal definition of physical abuse. The CNA involved was terminated for not meeting service standards, but was not available for interview. The executive director did not participate in the surveyor's investigation, and the interim administrator who conducted the internal investigation was no longer with the facility. Facility policy defines abuse broadly, including physical and mental abuse, but the investigation failed to apply these standards to the incident.