F0610

D

Failure to Thoroughly Document and Investigate Abuse Allegation

Waterloo, Iowa Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to thoroughly investigate an allegation of physical abuse made by Resident #3 against a respiratory therapist (Staff G). Resident #3 had intact cognition with a BIMS score of 15 and multiple diagnoses including paraplegia, seizure disorder, respiratory failure, malnutrition, major depressive disorder, antisocial personality disorder, and PTSD. The resident’s care plan emphasized psychosocial well-being, including interventions to assist the resident in processing feelings, verbalizing concerns, and validating and resolving complaints. Despite this, when Resident #3 alleged physical abuse by Staff G, the facility’s subsequent investigation did not fully document all relevant information and interviews.

The facility’s self-reported incident documentation stated that, after completing interviews with Resident #3 and staff, there was no evidence to support the allegation and that Resident #3 reported feeling safe with Staff G and denied that Staff G was physically rough or provided care without explanation. However, the investigation file contained only limited written statements dated 2/22/26: an interview by Staff F (MDS coordinator) with Resident #3, an interview with Staff H that lacked Staff H’s signature, and an interview with Staff G by the DON that lacked Staff G’s signature. The investigation documentation omitted written witness statements that Staff H reported having written, as well as the original statement Staff H helped Resident #3 write, which Staff F reportedly took. The investigation also lacked documentation of interviews with three additional residents and three additional staff members whose names were later provided by the DON.

Interviews with staff further highlighted gaps in the investigation record. Staff H confirmed that on the date of the incident they were working with Resident #3, received the abuse allegation against Staff G, immediately notified the administrator and Staff F, and wrote a witness statement before assisting Resident #3 in writing a statement with an LPN present. Staff F confirmed being notified of the allegation, coming into the facility, speaking with Staff H, the LPN, and Resident #3, and using Staff H’s written statement to write statements for both Staff H and Resident #3. Staff G confirmed being contacted by the DON about the alleged incident but reported no further contact from the facility. The facility’s abuse policy required timely, thorough, and objective investigations with documentation of the allegation and collection of supporting documents, but the investigation file lacked complete, signed statements and documentation of all resident and staff interviews referenced by the facility, resulting in a failure to maintain evidence that the allegation was thoroughly investigated.