Failure to Investigate Allegation of Verbal and Physical Abuse
Penalty
Summary
The facility failed to conduct a timely and thorough investigation of an allegation of verbal and physical abuse involving one resident. Facility policy required that all reports of abuse, including verbal and physical abuse, be promptly and thoroughly investigated, with the investigation begun immediately and including interviews with the involved resident, alleged perpetrator, other residents, and staff, as well as steps to protect residents. Resident #1, who was cognitively intact per a recent MDS with a BIMS score of 13 and dependent on staff for ADLs with diagnoses including hemiparesis, respiratory failure, and traumatic spinal cord dysfunction, reported that a CNA the resident referred to as “Firehead” had been rude. The Administrator stated that CNA B reported to the DON and ADON that Resident #1 said this staff member, later identified as CNA A, squeezed the resident’s face and told the resident to shut up. Resident #1 later described that the staff member entered the room, yelled at the resident to shut up, and squeezed the resident’s cheeks very hard, causing pain and fear. The Administrator initially considered the report could be abuse but interviewed the resident with CNA A present, and when the resident denied the allegation in that setting, the Administrator did not report the allegation to the state agency and did not initiate or complete an investigation. Review of facility documentation showed no interviews or statements from the alleged perpetrator, other staff, residents, or witnesses, and no evidence of a thorough investigation. The Administrator later clarified that the incident had been reported to her on January 9 but still had not been investigated at the time of the surveyor’s review.
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