Failure to Thoroughly Investigate Alleged Physical Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of witnessed physical abuse involving a resident who was cognitively intact and dependent on staff for most activities of daily living. The incident occurred when a nursing assistant (NA) was observed by a registered nurse (RN) to punch the resident in the leg during care. The resident confirmed feeling unsafe and described being struck by the NA, and both the NA and RN provided statements regarding the incident. Despite this, the facility's investigation did not include interviews with other residents to determine if they had experienced or witnessed abuse. The investigation process involved interviewing staff members about general experiences with mistreatment but did not include specific questions about the incident or the staff involved. Sixteen staff members were asked if they had ever mistreated a resident or witnessed mistreatment, but there was no documentation of targeted questions regarding the alleged abuse involving the NA and the resident. Additionally, the investigation did not include interviews with residents from other units where the NA had worked, nor were families interviewed. The facility limited its resident assessment to skin and pain checks and baseline emotional and psychological observations, without directly asking residents about abuse or safety concerns. The director of nursing and the administrator indicated that residents on the cognitive unit were not interviewed due to concerns about their ability to provide accurate responses, and residents from other units were not interviewed because the incident was considered isolated. The facility's policy required interviewing all individuals who might have knowledge of the incident, including the alleged victim, perpetrator, witnesses, or others with related contact, but this was not followed in the investigation.