Failure to Obtain Required Staff Witness Statements in Abuse Investigations
Penalty
Summary
The deficiency involves the facility’s failure to follow its own abuse, neglect, mistreatment, and misappropriation policy by not obtaining required written statements from all involved and witness staff during abuse-related investigations. The facility policy states that when an incident or suspected incident of abuse is reported, the Administrator or designee will promptly and thoroughly investigate, including obtaining statements from involved staff and witnesses. For one resident with Alzheimer’s disease and senile degeneration of the brain, who was severely cognitively impaired and dependent on staff for activities of daily living, a five-day report documented unexplained bruising on the right upper arm and left thigh. The investigation file listed specific nursing staff, including an LPN and multiple CNAs, as having cared for the resident during the relevant time frame, but the file did not contain statements from two of the CNAs identified as involved staff. The deficiency also includes an incident involving two residents with severe cognitive impairment, one with senile degeneration of the brain and the other with Alzheimer’s disease and vascular dementia. A five-day report documented that one resident wheeled over to another resident and pulled the other resident’s hair, causing the second resident to yell and resulting in scalp redness without skin breakdown. This event was treated as an abuse-related incident under the facility’s policy, which requires collection of involved staff and witness statements as part of the investigation. However, the survey findings indicate that for this incident, as with the unexplained bruising case, the facility did not fully implement its abuse investigation procedures by failing to obtain and maintain statements from all involved staff and witnesses as required by its written policy.
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