Failure to Thoroughly Investigate Alleged Abuse Incident
Penalty
Summary
Surveyors found that the facility failed to thoroughly investigate an alleged incident involving possible abuse, neglect, or mistreatment of a resident. The incident involved a Licensed Practical Nurse (LPN) who was observed on video surveillance engaging in a verbal exchange with a resident, followed by the LPN forcefully pulling the resident, who was seated in a wheelchair, back into their room despite the resident's resistance. The facility's internal investigation concluded that no abuse, neglect, or mistreatment had occurred, but the investigation summary did not include a review of the video surveillance footage or documentation of an interview with the resident's roommate, who was present during the incident. The resident involved had diagnoses including aphasia, cerebral infarction, hemiplegia, and was status post revision of a right total knee arthroplasty. According to the most recent assessment, the resident was independent with eating and bed mobility, required supervision and setup assistance with transfers and toileting, and was independent with wheelchair mobility, but had moderately impaired cognition. The incident was initially reported after a Certified Nurse Aide observed the LPN speaking loudly to the resident and allegedly pulling the resident by the shoulders while maneuvering the wheelchair. The LPN reported attempting to assist the resident back into a seated position and move the wheelchair to clear the path for the medication cart. Despite the availability of video surveillance footage, the facility's investigation summary did not document a review of this footage, nor did it include an interview with the roommate who witnessed the event. Both the Director of Nursing and the Administrator acknowledged that the omission of the video review from the investigation summary was an oversight. The facility's policy requires that all investigations be thorough and complete, including reviewing all relevant evidence and interviewing witnesses, but these steps were not fully documented in this case.