Failure to Investigate and Report Alleged Neglect
Penalty
Summary
A deficiency was identified when the facility failed to thoroughly investigate and take corrective action regarding an allegation of neglect involving a resident with multiple medical conditions, including heart failure, diabetes, and chronic incontinence. The resident, who was always incontinent of bowel and bladder, reported that after requesting incontinence care from a CNA, she was told to wait due to staffing shortages. The resident subsequently blocked the CNA in her room, demanding assistance, and ultimately received care from other staff members several hours later. Interviews with staff revealed that the facility was short-staffed on the day of the incident, and the CNA involved reported the altercation to both an LPN and the ADON. The LPN, after being informed of the situation, contacted the ADON for guidance but was told to handle the situation without further instruction. The CNA also reported the incident to the DON and the ADON, but was not asked to provide a written statement, and was later not permitted to care for the resident. There was no documentation in the resident's clinical record regarding the incident or the alleged neglect. Further interviews with facility leadership, including the DON, ADON, and Administrator, confirmed that the incident was not thoroughly investigated, statements were not collected, and the event was not reported to the state agency as required by facility policy. The facility's policy mandates immediate and thorough investigation of all alleged violations, including interviews, documentation, and reporting to the appropriate authorities, none of which were completed in this case.