Failure to Thoroughly Investigate Allegations of Abuse and Exploitation
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and exploitation involving one cognitively intact resident, R4. R4, who had diagnoses including drug-induced adrenocortical insufficiency, rheumatoid arthritis, anxiety, and depression and a BIMS score of 14/15, filed a grievance stating that a CNA told R4 they could not get out of bed if they only wanted to be up in a wheelchair for an hour. The grievance, reviewed by the DON, was summarized as R4 requesting to get up but changing their mind due to the length of time they would need to remain in the wheelchair, and staff were noted as having been educated on residents’ rights to choose when to be out of bed. However, the facility did not interview other residents or staff to determine if similar incidents had occurred, and the CNA involved was not removed from resident care during the investigation. The NHA and DON later acknowledged that a more thorough investigation of this abuse allegation should have been completed. The facility also did not fully investigate an allegation of potential exploitation when R4 reported having purchased and given a tumbler/mug as a gift to the same CNA. R4 told the social worker designee that attorneys had advised R4 to inform the facility about the gift and acknowledged knowing residents were not supposed to give gifts to staff. The DON confirmed that R4 reported buying a mug for the CNA, that the CNA initially refused it multiple times but ultimately accepted it due to pressure from R4, and that the mug was later returned. Although the facility had documentation that staff were educated on not accepting gifts from residents, there was no evidence that other residents or staff were interviewed to determine whether other gifts had been given and accepted. The NHA and DON agreed that the allegation of exploitation was not investigated thoroughly.
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