Failure to Thoroughly Investigate and Protect Residents Following Abuse Allegations
Penalty
Summary
The facility failed to ensure that allegations of abuse involving two residents were thoroughly investigated, as required by its own policies and federal regulations. In the first instance, a staff member reported that a certified nursing assistant (CNA) was rough and yelled at a resident during a transfer, with the resident's pant leg becoming stuck in the wheelchair. The facility's investigation consisted only of three handwritten interviews lacking interview times and signatures, and did not include interviews with other staff or residents. The nursing home administrator confirmed that no additional interviews were conducted and that the CNA was not suspended or removed from patient care during the investigation. There was also no evidence that protective measures were put in place to prevent further potential abuse during the investigation process. In the second instance, a family member reported concerns about the approach staff used while transferring another resident with an EZ stand, describing the staff as abrupt and communicating inappropriately. The family member stated that staff made negative comments about the resident's motivation and compliance, and told the resident she could remain in the chair. The facility provided interviews with the resident, the family member, and two CNAs (only one of whom was present during the incident). Although the facility provided documentation of staff education on resident approach and abuse policy, the nursing home administrator acknowledged that a full investigation was not completed and that the incident was not reported to the state as required. Both cases demonstrate that the facility did not follow its own abuse policy, which mandates immediate safeguarding of residents, thorough investigation of all alleged violations, and reporting to the state agency within specified timeframes. The lack of comprehensive investigations and failure to implement protective measures for the residents involved resulted in noncompliance with regulatory requirements for responding to allegations of abuse.