Failure to Conduct Thorough Abuse and Misappropriation Investigations
Penalty
Summary
The deficiency involves the facility’s failure to conduct thorough investigations into allegations of abuse and misappropriation, contrary to its own abuse investigation policy. The policy, updated in October 2022, requires the administrator/abuse coordinator to oversee investigations and ensure identification and interviews of the alleged victim, alleged perpetrator, witnesses, and others with knowledge of the allegation. Surveyors found that these requirements were not followed in two separate incidents involving alleged sexual abuse of one resident and missing narcotic medication for another resident. In the first case, a resident with bipolar disorder, agoraphobia, and anxiety disorder, who had intact cognition and was dependent on staff for toileting and personal grooming, reported that a staff member made inappropriate comments and touched them inappropriately while providing peri-care. The facility’s investigation identified a NAC as the alleged perpetrator and documented that the incident occurred on a specific date. The investigation included statements from two NACs and two nurses who worked the evening shift, as well as a statement from the Resident Care Manager. However, both NAC statements indicated the alleged incident occurred during the day shift, and no staff from that day shift were interviewed. A NAC identified in a witness statement as the first person to whom the resident reported the allegation was not interviewed, and no statement from this NAC was obtained. The DNS, who was responsible for completing the investigation, acknowledged not interviewing any day-shift staff and stated they had not conducted further interviews beyond the statements already gathered. In the second case, the facility failed to thoroughly investigate missing narcotic medication for another resident. An investigation report documented that during narcotic count it was determined that the resident’s narcotic medication was missing and that the facility could not establish the location of the medication or whether it was lost or mistakenly destroyed. The incident report included a police report for theft and an email from the DNS describing the medication as misplaced, which was inconsistent with the investigation documentation. The incident report contained no witness statements and no statements from nurses who had recently worked the medication carts. The ADON described an established medication destruction process and required documentation, but the DNS stated they had not reviewed any destruction forms faxed to the pharmacy and had not gathered witness statements or interviewed other nurses who had worked the medication cart prior to discovering the medication missing. A night-shift RN reported notifying the DNS about the missing narcotics and being instructed to copy the narcotic book page and place it in the DNS’s box, but did not see or meet the DNS before leaving the facility, further underscoring the lack of follow-through in the investigation.
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