Failure to Investigate and Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to investigate an allegation of staff-to-resident abuse and did not implement its abuse prevention policy following an incident involving a resident with dementia and major depressive disorder. An anonymous allegation was received by the state regarding a staff member becoming aggressive with a resident during lunch. The Dietary Manager (DM) reported witnessing a certified nursing assistant (CNA) grab the resident's wrists and speak loudly after the resident scratched the CNA. The DM attempted to report the incident to the Director of Nursing (DON) and the Administrator, but the Administrator later indicated there were no findings and did not request a written statement from the DM. Interviews revealed inconsistencies in the facility's response to the allegation. The Administrator stated he was unaware of any abuse reports or grievances in the relevant period and did not consider the incident reportable. He also questioned the reliability of the DM as a witness due to prior conflicts between the DM and the CNA. The DON recalled the DM reporting the incident and attempting to check security cameras, but did not recall collecting written statements from involved staff. The facility's own policy required immediate reporting, separation of the alleged perpetrator, documentation, and notification to the state, none of which were fully followed. The resident involved was severely cognitively impaired and required cues for eating. Clinical records indicated behavioral symptoms related to dementia, but no physical or verbal aggression was documented during the assessment period. The facility's documentation of the incident was created over a month after the event and did not include timely written statements from all witnesses. The facility did not ensure that all required investigative steps were taken or that residents were protected according to policy following the allegation.