Failure to Thoroughly Investigate Alleged Verbal Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving a resident with autosomal dominant limb girdle muscle dystrophy and intact cognition. The incident began when the resident complained about a missing lunch tray, leading to a verbal altercation with the Dietary Coordinator (DC). Witnesses reported that both the resident and the DC exchanged profanities, with the DC telling the resident to "shut up" and continuing to use profanity while walking through the hallway, where other residents and family members were present. The facility's investigation concluded that the allegation of verbal abuse was unsubstantiated due to a lack of willful intent to harm the resident, although the DC was terminated for unprofessional conduct. However, the investigation did not include interviews with additional residents or family members who may have witnessed the DC's behavior in the hallway and dining area, despite staff statements indicating their presence during the incident. The investigation relied primarily on statements from staff directly involved or present during the altercation. Facility policy requires that all allegations of abuse be thoroughly investigated, including interviews with the resident, the accused, all witnesses, and potentially other residents and staff who may have been in close contact or present during the incident. In this case, the failure to interview additional residents or family members who were in the vicinity of the incident resulted in an incomplete investigation, as required by facility policy.