Failure to Thoroughly Investigate Staff-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident abuse involving one resident. The resident reported that during an argument with an agency LPN, he was struck by the nurse after he pushed the LPN. The incident occurred after the resident requested an insulin injection in the dining area, which the LPN refused, leading to a confrontation in the resident's room. Multiple witnesses, including a CNA and a family member, reported hearing or observing the altercation, with one CNA noting the resident had a bloody lip and stating that both the resident and LPN admitted to physical contact. A police report also documented the incident, with the LPN admitting to slapping the resident's hand away after being poked in the chest. Despite these accounts, the facility's investigation was incomplete. The interim DON only collected a written statement from one CNA and did not interview all staff or witnesses present during the incident, including another CNA and a family member who directly observed or heard the altercation. The facility's abuse policy requires a thorough investigation, including interviewing all involved persons and witnesses, but this was not followed. As a result, the incident of staff-to-resident physical abuse was not fully identified or documented, and there was a potential for additional abuse to go unrecognized.