Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident who was cognitively intact and had diagnoses including depression, COPD, and heart failure. The resident reported that a nurse aide forcefully grabbed her arm while attempting to take her to the dining room, causing soreness. The incident was reported by both the resident and her family, and an X-ray was ordered, but no unusual findings were noted on assessment. The resident provided a detailed statement describing the incident, including her attempt to return to her room, her holding onto a handrail, and the nurse aide lifting her arm to redirect her to the dining room. Facility documentation and witness statements collected as part of the investigation failed to address the specific allegation of the nurse aide forcefully moving the resident's hand from the handrail. Most witness statements focused only on care provided in the resident's room and did not mention the incident in the hallway. Interviews with staff, including the nurse aide involved and the Director of Nursing, confirmed that the investigation did not adequately address the resident's specific allegation. Facility leadership acknowledged that the investigation was incomplete and did not fully explore the reported abuse.