Failure to Complete Investigation of Verbal Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving one resident. The facility’s policy, revised 09/13/2022, required that all allegations of abuse, neglect, exploitation, and misappropriation of resident property be investigated, including identifying staff responsible for the investigation, interviewing involved persons and witnesses, determining whether abuse or mistreatment occurred, and documenting the investigation. Resident 5, who had diagnoses including kidney and urinary disorders, hypertension, and bipolar II disorder, and who required setup/cleanup assistance for ADLs, had intact cognition per a comprehensive assessment. An allegation was made that a registered nurse (Staff G) verbally abused this resident. The DON (Staff B) stated that their process for addressing abuse allegations included notifying the administrator, launching an investigation with witness statements, and reporting to required agencies. Staff B reported that an investigation into the alleged verbal abuse toward Resident 5 was initiated on the day of the incident and then given to the Administrator (Staff A) to complete because Staff B was out sick the following week. Staff B acknowledged that the investigation was not finished. The Administrator stated that the incident should have been investigated by the DON or turned over to the Resident Care Manager if the DON was unable to complete it, confirming that the required investigation was not completed.
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