F0610

D

Failure to Thoroughly Investigate Multiple Abuse Allegations and Document Law Enforcement Notification

Frederick, Maryland Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The facility failed to thoroughly investigate multiple allegations of abuse as required by its own process and regulatory expectations. For Facility Reported Incident (FRI) #351276, involving a resident who alleged that a GNA was rough and hit her while providing care, the investigation file lacked staff witness statements, a statement from the alleged perpetrator, and any resident witness statements or resident assessments. The only resident statement present was an undated questionnaire-style document for Resident #40 that lacked the interviewer’s name and signature. The file also did not contain evidence of the alleged perpetrator’s license, education, or work status, nor copies of both the initial and final reports to the Office of Health Care Quality (OHCQ). When questioned, the NHA and DON stated that the former DON wrote the resident’s statement and that other residents were interviewed and assessed, but they could not provide supporting documentation.

For FRI #351281, related to a resident admitted in April and discharged in May who reported that a staff member purposefully struck his left arm and handled him too aggressively, the medical record documented the allegation and a provider assessment noting no obvious signs of trauma. The investigation file contained an unsigned and unnamed statement describing the resident’s report, including that staff slapped the resident’s hand away while handling a urinal and that another staff member was present. The file also included a document signed by the NHA summarizing an interview with Staff #15, indicating the staff member claimed the contact was accidental, and an education acknowledgment signed by Staff #15, as well as a signed statement from Staff #14 who reported being in the room and not hearing a slap. However, there was no signed statement from Staff #15 in the file and no documentation that Staff #15 had been asked to provide a signed statement or had declined or was unavailable, despite corporate guidance that investigative statements should be conducted as interviews with factual data and supported by documentation.

For FRI #2623047, the initial report to OHCQ documented that the county sheriff’s office was contacted, but did not identify an officer, report number, or other objective evidence of the contact. The investigation file contained questionnaires reflecting resident and staff interviews but did not identify witnesses to the alleged incident. Within the investigation record, the section for law enforcement notification listed the sheriff’s office but left the date and time of contact blank. A follow-up report stated that a non-communicative resident had a skin assessment with no new areas noted, that residents were interviewed or assessed as applicable, and that the alleged perpetrator (Staff #18) was unaware of the incident due to lack of a specific date/time and was suspended pending investigation. The facility could not provide a signed statement from Staff #18 or documentation of attempts to obtain such a statement, and also could not provide objective documentation (such as date/time, name/badge of the officer, or report number) to verify law enforcement notification as reported to OHCQ.