Failure to Document Thorough Investigation of Abuse Allegation
Penalty
Summary
The facility failed to ensure that all incidents, including allegations of abuse, were thoroughly investigated as required by their Abuse Prevention Program policy. On the morning of 4/14/2025, a resident with a history of fractured rib, COPD, and chronic kidney disease, and a moderate cognitive impairment, reported being punched in the ribs by nursing staff. The resident's care plan included monitoring for pain and complications related to their rib fracture. Documentation showed that a full body assessment was completed with no signs of injury, and the resident's next of kin noted similar past allegations at other facilities. The investigation summary concluded that abuse was not substantiated, based on interviews with some employees, a physical assessment, the resident recanting their statement, and a pattern of behavior confirmed by the next of kin. However, there was no documented evidence that the overnight staff, who would have been present during the alleged incident, were interviewed as part of the investigation. The facility's policy required statements from all relevant staff, but the investigation report lacked documentation of interviews with the overnight shift. Interviews with facility staff, including the DON and Administrator, confirmed that while verbal interviews with the night shift were reportedly conducted, they were not documented or included in the investigation file. The lack of documentation of these interviews meant the facility did not meet the requirement for a thorough investigation of the abuse allegation, as outlined in their own policy and regulatory standards.