Failure to Thoroughly Investigate Allegation of Abuse
Penalty
Summary
The facility failed to provide evidence that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one resident. Specifically, a resident with multiple diagnoses, including dementia, schizoaffective disorder, and cognitive communication deficit, made an allegation that a hospice aide was rough during perineal care and did not stop when requested. Additionally, the resident alleged inappropriate sexual contact and racial slurs by a hospice aide. The investigation report completed by the previous administrator did not identify the alleged perpetrator, lacked documentation that hospice was notified, did not include safe surveys, and failed to provide evidence of abuse and neglect in-services being conducted. Interviews revealed that the hospice Director of Nursing was not notified of the allegation until months later, and the current administrator, who was not involved in the original investigation, could not locate further information or documentation regarding the incident. Facility policy required thorough documentation of incidents, including witness accounts, physician notification, and corrective actions, but these elements were missing from the investigation. The resident later stated they did not recall the alleged abuse, but the lack of a comprehensive investigation and documentation was evident.