Failure to Thoroughly Investigate Abuse Allegation and Restrict Alleged Perpetrator
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse and to prevent further potential abuse involving a cognitively intact resident with bipolar disorder, anxiety, and insomnia. The resident, admitted in June 2022, reported to an RN on the 3:00 PM to 11:00 PM shift on 3/4/2026 that a NA had been too rough with him/her during care on the prior 3:00 PM to 11:00 PM shift, stating that the NA hurried him/her to bed and twisted his/her arms while pivoting from chair to bed. The facility’s abuse policy required that anyone suspecting abuse notify the charge nurse, DNS, and/or Administrator at the time of the incident and that a full investigation be conducted, including written statements from witnesses and the resident. However, the investigation initiated after another RN returned from several days off and reviewed the progress notes did not contain a statement from the RN who originally received the allegation (Staff A) or from the RN assigned to the resident during the shift when the alleged incident occurred (Staff D). The only written statement from the alleged perpetrator, the NA, simply denied twisting the resident’s arm and leg and did not provide further detail about the events. The facility also failed to prevent further potential abuse while the investigation was in progress. A facility-reported incident submitted to the state agency documented that a small blue mark of unknown etiology was later noted on the resident’s right outer thigh during a skin check. Although the facility indicated that the NA would no longer be assigned to care for this resident, the staffing schedule showed that the NA continued to work in the facility on the evenings of 3/4/2026 and 3/5/2026, providing care to other residents after the allegation had been made. During interview, the Administrator acknowledged that key staff statements were not obtained and that the NA was allowed to continue working with other residents after the abuse allegation was reported.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.