Failure to Thoroughly Investigate and Protect Residents During Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving two residents with severe cognitive impairment. The incident was reported to the Director of Nursing (DON) by a CNA who overheard another CNA making threatening statements to residents, including threats to 'slap' and 'beat' them. The DON notified the Nursing Home Administrator (NHA), who arrived at the facility, spoke with staff, and requested written statements. However, the investigation did not include interviews with the residents involved, despite their cognitive impairments, and relied primarily on staff statements and a skin check conducted the following morning. The facility's policy requires immediate intervention to ensure resident safety, including removing the alleged perpetrator from the facility and suspending them from duties during the investigation. Although the accused CNA was initially sent home, records show that the CNA continued to work at the facility on subsequent days while the investigation was ongoing. This failure to remove the accused staff member from resident care duties meant that resident safety was not ensured during the investigation period. Additionally, the facility did not report the abuse allegation to the state agency within the required two-hour timeframe, as acknowledged by both the NHA and DON during interviews. The investigation was incomplete, lacking resident interviews and timely reporting, and did not fully adhere to the facility's own abuse investigation and reporting policies. The documentation provided by the facility included staff education and signature sheets, but did not demonstrate a comprehensive or timely response to the abuse allegation.