Failure to Immediately Investigate and Prevent Further Potential Abuse Following Allegation
Penalty
Summary
A deficiency occurred when the facility failed to respond appropriately to an allegation of physical abuse involving a resident with severe cognitive impairment, dementia, anxiety, and type 2 diabetes. The incident involved a staff member allegedly witnessing another staff member slap the resident during a shower. Despite the facility's policy requiring immediate initiation of an investigation and interventions to prevent further abuse, there was a delay in starting the investigation, and the accused staff member continued to work subsequent shifts after the allegation was made. The investigation file lacked evidence that it was initiated immediately upon the report of abuse. Written statements from staff were dated several days after the incident, and there was no documentation that the accused staff member was contacted for a statement. Additionally, there was no evidence that other residents cared for by the accused were assessed or interviewed to determine if there were additional victims. Progress notes for the days following the incident did not document any assessment of the resident for injuries until several days later, when a nurse practitioner noted no injuries. Interviews with staff revealed that the initial report of abuse was made to a registered nurse, who did not document an assessment or initiate an incident report. The accused staff member was not immediately removed from resident care and continued working until terminated for an unrelated reason. The Director of Nursing and Administrator confirmed that the investigation was not started until days after the incident and that key investigative steps, such as interviewing the accused and assessing other potentially affected residents, were not completed. The facility's failure to follow its own abuse investigation policy resulted in a lack of timely and thorough investigation and did not prevent further potential abuse or mistreatment while the investigation was in progress.