Failure to Investigate Potential Neglect for Two Residents
Penalty
Summary
The facility failed to thoroughly investigate potential neglect for two residents, R23 and R24. For Resident R23, who was admitted with conditions including high blood pressure, peripheral vascular disease, and diabetes, the facility did not change the wound dressing on the left shin as ordered on multiple occasions. Despite the Treatment Administration Record indicating that the dressing was changed, an observation revealed that the dressing was dated several days prior, and staff confirmed it was not changed as required. The investigation into this incident did not include witness statements from staff who signed off on the dressing changes. For Resident R24, who had diagnoses including sepsis, hydrocephalus, and seizures, an incident occurred where the resident was found crawling on the floor in a puddle of blood with a cut above the right eye. The resident was sent to the hospital for evaluation. The facility's investigation into this incident failed to include signed and dated witness statements from the resident's roommate and staff who had contact with the resident during the shift when the incident occurred. The Director of Nursing confirmed the lack of thorough investigation to rule out potential neglect.
Plan Of Correction
1. Facility will attempt to obtain witness statements for events related to R23 and R24, and events will be reported in ERS. 2. DON/designee will complete a 6 month look back for other incidents to rule out abuse/neglect and report as needed. 3. DON/designee to educate nursing staff on abuse/neglect and requirements of a thorough investigation. 4. The DON/Designee will audit all Incident Reports to ensure a thorough investigation weekly x 2 weeks, then 5 incident reports per week x 3 weeks. 5. Results to be submitted to QAPI for review and approval.