Failure to Thoroughly Investigate Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to conduct thorough investigations into multiple abuse-related incidents involving three residents. For one resident, the facility documented facial gashes after an event that required transfer to a higher level of care, suturing of two right lower facial lacerations, and identification of an intracranial hemorrhage. Facility leadership concluded the resident caused the injuries by striking her teeth on the bed siderails and stated they had no reason to investigate the resident’s former roommate, despite that roommate’s documented history of aggressive behaviors and prior episodes of becoming upset with other residents. Hospice staff had emailed the Administrator requesting the resident be moved due to concerns about the roommate’s history of violent behaviors, and the resident was moved several days after returning from the hospital. In a separate incident, the facility received an allegation of verbal abuse in which a dietary staff member reported witnessing a CNA pull a resident by the arm of his wheelchair and yell at him. The facility’s investigation concluded the allegation was unsubstantiated, citing an inability to obtain adequate information from the reporting staff member after his resignation, even though leadership knew he resigned due to workplace harassment following his report, and no further investigation was conducted. In another case, a resident alleged that an RN became upset and threw a clipboard at him, resulting in a documented bruise on his hand when he blocked the clipboard. Facility leadership stated the allegation was unsubstantiated based on a reported retraction relayed by the ADON and a note that the resident had signed something with the police; the IDT added “confabulation – allegations of staff abuse” to the resident’s record. However, the resident later stated he only declined to press charges and did not retract the allegation. The police report documented that the resident declined to press battery charges and that the Risk Manager questioned why the incident was reported two days after it occurred, and the facility’s investigation consisted only of the Risk Manager’s written statement that the resident declined to press charges, with no additional investigative documentation provided.
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