Failure to Thoroughly Investigate and Document Alleged Abuse, Neglect, and Mistreatment
Penalty
Summary
The facility failed to appropriately respond to and thoroughly investigate multiple alleged violations related to abuse, neglect, exploitation, mistreatment, and injuries of unknown source. In several cases, allegations made by residents with intact cognitive status were not promptly or fully investigated, and required documentation such as witness statements, staff interviews, and resident interviews were missing or incomplete. For example, one resident reported being left soiled for four hours and not being assisted with meals, but the investigation lacked statements from staff or other residents who may have had knowledge of the incident. In another case, a resident alleged physical abuse and not receiving a meal tray, but there was no documentation that the incident was reported to all required state agencies, and no witness statements or follow-up documentation were present. Other incidents involved allegations of sexual abuse, neglect related to pressure ulcer development, and being left soiled for extended periods. In these cases, investigations were either delayed, lacked comprehensive interviews, or failed to document actions taken to determine the facts. For instance, a nursing assistant reported concerns about a resident developing a pressure sore, but the investigation concluded with an unsigned note attributing the issue to a communication and technology error, without addressing the specific failures in communication or documentation. In several cases, statements collected were undated, unsigned, or lacked sufficient detail, and follow-up actions such as call light audits were either not performed as described or not documented. Throughout the reviewed incidents, there were repeated failures to collect and document all relevant information, including statements from all staff and residents who may have had knowledge of the events, and to report allegations to the appropriate authorities in a timely manner. Investigations were often deemed inconclusive due to conflicting statements, but no secondary interviews or clarifications were attempted. In some cases, corrective actions or plans to prevent recurrence were not documented, and required follow-up reports were missing from the files. These deficiencies were confirmed by the administrator and DON during interviews, who acknowledged missing documentation and incomplete investigations.