Failure to Thoroughly Investigate Resident Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of verbal and physical abuse in accordance with its policy titled "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating" for two residents. The policy required that all reports of resident abuse be thoroughly investigated by facility management, with the Administrator initiating the investigation and the individual conducting the investigation documenting it completely and thoroughly. One resident, with a Brief Interview for Mental Status (BIMS) score of 13 indicating little to no cognitive impairment, reported via a grievance that a CNA was very rough while changing her brief, pushing on her shoulder while trying to turn her. Progress notes documented that this resident complained of shoulder pain and stated the CNA was rough when turning her, and a subsequent skin assessment was completed. However, there was no additional documentation related to the abuse allegation reported on that date and no record of a thorough investigation of the allegation. A second resident, also with a BIMS score of 13 indicating little to no cognitive impairment, filed a grievance stating that the same CNA handled the resident very roughly and was rude during care. Record review revealed no documented thorough investigation of this resident’s allegation of abuse. Interviews with facility leadership confirmed that the Administrator only interviewed the two residents about the CNA being verbally abusive and handling them roughly during ADL care and did not conduct or document any further investigations into the allegations, despite the facility’s policy requiring comprehensive investigation and documentation of all abuse allegations.
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