Failure to Thoroughly Investigate Allegation of Staff Intentionally Throwing Urine on Resident
Penalty
Summary
Facility staff failed to conduct a thorough investigation of an allegation of abuse involving a resident who reported that a GNA intentionally poured and then flicked urine on them, including onto their face. The incident began when the resident, who was unable to hold a urinal independently due to having only one usable hand, requested assistance from an agency GNA on the night shift. According to the GNA’s written statement, she initially attempted to assist the resident to use the urinal, realized she was not wearing gloves, tried to place the urinal in the resident’s hand, and the resident pulled their arm back aggressively, causing her to drop the urinal and spill urine. The GNA reported that the resident then yelled at her and threw the urinal at her as she left the room, causing urine to splash on her, the wall, and the ceiling. The facility’s investigation documentation reflected these accounts and noted that the GNA denied intentionally pouring urine on the resident. In contrast, the resident consistently reported to the DON, a police officer, and later to surveyors that the GNA intentionally poured urine onto their lap after the resident protested that the urinal was not positioned properly, and then, after the resident threw the urinal at the wall, the GNA picked it up and flicked urine at the resident, causing urine to splash onto the resident’s face. The resident’s family member also reported to the facility that the resident said a nurse threw urine in their face. Despite these specific allegations that urine was intentionally thrown or flicked into the resident’s face, the facility’s investigation records did not show that Staff #5 was ever questioned about throwing or flicking urine at the resident’s face, nor did the written investigation address this aspect of the allegation. The final investigation documentation focused on whether urine was accidentally spilled and whether the resident threw the urinal, and concluded the allegation was inconclusive, without evidence that the specific claim of urine being thrown into the resident’s face was investigated.
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