Failure to Investigate Neglect and Conduct Background Check
Penalty
Summary
The facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an allegation of neglect for a resident. The resident, who had diagnoses of high blood pressure, anemia, and hyperlipidemia, expressed concern about her care during a physical therapy evaluation. She reported that she had activated her call light between 11:00 a.m. and 11:30 a.m. to request assistance with changing, but the aide turned off the call light without providing the needed care, returning only at 1:40 p.m. to assist her. The facility's grievance form noted that staff were interviewed and educated about the proper handling of call lights, and the resident was informed of this action. However, the Social Services Director did not report the incident as neglect, despite the resident's distress during a follow-up conversation. Additionally, the facility failed to conduct a criminal background check for a dietary employee before their employment began. The employee's file, reviewed on a later date, did not contain documentation of a completed background check, which was confirmed by the Director of Human Resources. This oversight is a violation of the facility's policy requiring background checks to screen for any history of abuse, neglect, exploitation, or misappropriation of resident property.
Plan Of Correction
Resident R6 incident was reported on 1/27/25. House audit completed to ensure submission of any other incidents that involve abuse/neglect. Education on reporting process will be provided to the social worker and interim DON by the NHA or designee on or before 2/11/2025. Audits will be conducted on correct and timely submission of incidents on reporting process by DON or designee weekly x 4 weeks and monthly x 1 month. Audit results will be reviewed through the monthly QAPI process/meeting.