Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate allegations of abuse involving a resident with moderate cognitive impairment, dementia, and behavioral issues. The resident, who was dependent on staff for several activities of daily living, made multiple accusations against staff, including being hit, kicked, and punched. On specific occasions, staff members heard noises and observed the resident yelling out in pain, with one CNA reporting hearing a 'smack' and the resident immediately accusing a nurse of hitting her. Multiple staff members documented the resident's repeated claims of being struck by a staff member, and these incidents were reported to supervisory staff. Despite these allegations, the facility did not initiate a formal investigation as required by its own policy. Witness statements were collected by some staff and left for the Administrator, but key steps were omitted: the alleged perpetrator was not placed on leave, no skin assessment was performed on the resident, and other potential witnesses were not interviewed. Staff who reported the incident or wrote statements were not interviewed about the event, and the Administrator confirmed that no investigation was conducted due to the resident's history of making false allegations. The facility's policy required that all allegations of abuse be investigated, including securing the resident, assessing for injury, identifying the alleged perpetrator, notifying appropriate parties, and obtaining interviews or statements from all involved. These procedures were not followed in this case, resulting in a failure to respond appropriately to the alleged violations as required.