Failure to Thoroughly Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with impaired cognition and multiple complex medical diagnoses, including anxiety disorder, seizure disorder, malignant neoplasm, delusional disorder, atrial fibrillation, hypertension, and multiple sclerosis. The resident, who was dependent on staff for activities of daily living, alleged that an LPN grabbed her arms during a disagreement, resulting in discoloration. The facility's investigation consisted only of statements from the LPN and the resident, with the LPN attributing the discoloration to the resident being struck by a call light during the incident. No additional witness statements or documentation were collected, and the investigation was closed shortly after the incident was reported. Review of the facility's policy on abuse, neglect, and exploitation indicated that a thorough investigation should include interviews with all involved parties and documentation of all investigative steps. However, the facility's investigation lacked documentation in the resident's progress notes and did not include statements from any other potential witnesses or staff who may have had knowledge of the incident. The administrator confirmed that the investigation was incomplete and did not meet the facility's policy expectations.