Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving one resident. The incident occurred when staff responded to the resident screaming for help and found the resident on the floor after an altercation with a nurse aide. The resident reported that the nurse aide pulled a pillow from under them, causing them to fall, and then sprayed them with disinfectant spray. Witness statements from housekeeping and other staff corroborated that the nurse aide was laughing, yelling at the resident, and spraying their legs with an aerosol substance. Multiple staff members wrote witness statements and submitted them to administration. Despite these accounts, the facility's abuse investigation did not include the witness statements from the staff in the documentation. The administrator determined the allegation could not be substantiated due to an inability to prove intent and conflicting accounts, but acknowledged that the determination was not supported by the totality of evidence. The resident involved had a history of moderate cognitive impairment and other medical conditions. The facility's actions did not align with its policy to thoroughly investigate all alleged violations.