Failure to Conduct Thorough Investigations into Abuse and Misappropriation Allegations
Penalty
Summary
Facility staff failed to conduct thorough investigations into multiple allegations of abuse and misappropriation involving four residents. In one incident, a resident with a traumatic brain injury physically assaulted another resident in the smoking area, resulting in injury. Documentation of the incident was incomplete, lacking details such as staff witness statements and identification of all individuals present. Interviews revealed that no staff were present during the incident, and the assigned staff member for supervision was not interviewed as part of the investigation. The investigation file contained only a single resident witness statement and did not include comprehensive evidence collection or interviews with all potential witnesses. In another case, the same resident assaulted a different resident in the hallway, and there was a lack of evidence that a thorough investigation was conducted. The investigation file did not indicate that either resident or any staff were interviewed, nor were attempts made to identify additional witnesses. Documentation showed that the resident was on one-to-one supervision at the time, but there was no evidence that the assigned staff member was interviewed. The clinical records and incident summaries provided were insufficient to demonstrate a complete investigation into the events. Additionally, a resident reported missing money after being moved to a different room, but the facility failed to provide credible evidence of an investigation. The investigation file contained only an incident summary, a facility synopsis, and a handwritten, undated, and unsigned statement. There was no indication that staff interviews were conducted or that efforts were made to determine if anyone had seen the money prior to the report. The facility's own policies require immediate and thorough internal investigations, including evidence collection and interviews, but these procedures were not followed in the cases reviewed.