Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with multiple diagnoses, including dementia, Parkinson's disease, and mild cognitive impairment. The incident involved another resident who became agitated and grabbed the resident's shoulders, as confirmed by interviews with the resident, her representative, and an LPN who intervened. The resident reported a stress-induced headache following the incident, which was treated with a pain reliever. Documentation in the medical record and investigative documents did not accurately reflect the physical interaction, instead stating there was no evidence of physical contact. The investigation conducted by the facility was incomplete, as it did not include interviews with all relevant witnesses, specifically the resident's representative who was present during the incident. The DON stated she was unaware of any reports or documentation indicating physical contact and did not document her interview with the resident. The facility's policy requires a thorough investigation of all abuse allegations, including interviews and documentation, but these steps were not fully carried out in this case.