Failure to Thoroughly Investigate and Accurately Document Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and accurately document multiple abuse allegations, contrary to its Abuse, Neglect and Exploitation policy requiring immediate investigation and complete documentation. For one incident, two cognitively intact or moderately impaired residents were involved in a resident-to-resident altercation in which one resident allegedly spat on the other and the other allegedly struck back. The Director of Nursing documented hearing a commotion and observing spit on a resident’s shirt at a specific time, but the Facility Incident Report Form omitted the time of the incident, and the exception reports for each resident listed conflicting times. The investigative summary sent to the state survey agency did not include the time of the incident or when the Administrator, who served as Abuse Coordinator, was notified. In a second incident, a non-verbal resident with a history of stroke, TBI, major depressive disorder, and anxiety allegedly pointed to their genitalia and then to a Certified Medication Assistant, prompting an abuse allegation. The Facility Incident Report Form categorized the event as “Other” and noted that an investigation was initiated, but it did not document the time of the incident. The facility’s investigation documents for this event also did not indicate when the Administrator/Abuse Administrator was notified of the allegation, omitting key timing information required for a complete investigation. In a third incident, a resident with severe cognitive impairment and diagnoses including major depressive disorder, anxiety, dementia, and schizoaffective disorder allegedly was slapped by another severely cognitively impaired resident. The Facility Incident Report Form documented the date but not the time of the incident, and the investigation documents did not show when the Abuse Coordinator was informed. In a fourth incident, a cognitively intact resident reported that a CNA was rough with them. The Facility Incident Report Form again omitted the time of the incident, and an Exception Report showed the Administrator reviewing the incident on a date that conflicted with the alleged occurrence date. The investigation documents did not include when the Administrator was notified. Both the DON and the Administrator later stated their expectation that investigations include the exact date and time of the incident and the time the Abuse Coordinator was notified, which was not met in these cases.
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