Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of neglect involving a resident with dementia, muscle weakness, and a history of falls. The resident was admitted with a care plan indicating potential for skin integrity impairment due to fragile skin, impaired mobility, bladder incontinence, and a history of skin tears. A physician's order was in place to treat a skin tear on the resident's right forearm. However, an incident report noted a bruise on the resident's occipital bone and a skin tear near the right elbow, which was not properly cleansed before being dressed by a nurse aide. The Director of Nursing acknowledged awareness of the situation but did not investigate or report it as neglect. The nurse aide involved admitted to applying a bandage without cleansing the wound after failing to locate a nurse. The facility's failure to investigate the incident as neglect was confirmed by the Director of Nursing, indicating a deficiency in adhering to the facility's policy on abuse and neglect investigations.
Plan Of Correction
Incident with R1 was investigated and reported to the Department of Health on 12/26/24. The resident had sustained a skin tear, and a team member became aware of the skin tear when the daughter reported it during her visit on 12/16/24. The Executive Director of Health Services confirmed that the CNA did apply a tegaderm dressing and failed to report it to the nurse. A PB22 was completed, and the allegation of neglect was substantiated and addressed internally through corrective action. The skin tear was appropriately treated on 12/16/24 by the RN charge nurse and documented accordingly. The wound is healing properly. An audit of incidents and accidents from the time of this incident will be reviewed to ensure that they have been investigated properly and any potential allegations of abuse or neglect have been properly reported. Any identified issues will be reported at the time of discovery. The Director of Nursing and NHA were reeducated by the Senior Clinical Services Director on January 3, 2025, on the policy to respond to allegations of abuse, neglect, exploitation, or mistreatment. Any alleged violations have been thoroughly investigated with evidence of interventions to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident. If the alleged violation is verified, appropriate corrective action must be taken. Audits will be completed monthly for 3 months of any abuse allegations received by the facility to ensure the investigation is thorough and allegations are reported to DOH if appropriate by NHA or designee. Results will be brought to QAPI to determine if further auditing is necessary.