Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of neglect involving a resident, identified as Resident R6. 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, stating there were many call lights on. The aide did not return to assist the resident until 1:40 p.m., leaving the resident without necessary care for an extended period. The facility's policy on abuse, neglect, and exploitation requires an immediate investigation when there is suspicion or reports of neglect. However, the Nursing Home Administrator confirmed that no investigation was conducted regarding the resident's allegation. The Social Services Director spoke with the resident, who became upset and cried, expressing concern about getting staff in trouble. Despite this, the incident was not reported as neglect, and the facility did not fulfill its obligation to investigate the allegation thoroughly, as required by their policy and state regulations.
Plan Of Correction
Resident R6 incident reported on 1/27/2025. Education on completing a thorough investigation will be provided to the social worker by the NHA or designee on or before 2/11/2025. Audits will be conducted on all incidents by completing a thorough investigation by DON or designee weekly x 4 weeks and monthly x 1 month. Audit results will be reviewed through the monthly QAPI process/meeting.