Failure to Conduct Thorough Abuse and Neglect Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into multiple allegations of abuse and neglect involving five residents. In the case of two cognitively impaired residents, one alleged inappropriate touching by their roommate. The investigation did not identify which staff member initially received the report, and the original reporter was not asked to provide a written statement. The investigation relied solely on statements from the two residents, both of whom had significant cognitive impairment, and did not include interviews with other staff or witnesses who may have had relevant information. For another resident receiving hospice care, a fall resulted in a head injury. The resident's roommate later alleged that a nursing assistant had been rough and verbally harsh, contributing to the fall. The investigation included general questions to other residents about their care but did not specifically address the allegation. No interviews were conducted with other staff who may have had knowledge of the incident, and the statement from the accused nursing assistant was not signed or dated. Additional allegations of rough treatment and verbal aggression by the same nursing assistant were made by two other residents. These investigations also lacked specific interviews with the accused staff member regarding the allegations, did not include targeted questions to other residents, and failed to gather statements from other staff who might have relevant information. The facility's approach was to ask general, open-ended questions rather than specific ones related to the incidents, and the investigations were incomplete as a result.