Failure to Conduct Thorough Investigations of Abuse, Neglect, Falls, and Medication Errors
Penalty
Summary
The facility failed to conduct thorough investigations into multiple incidents involving allegations of abuse, neglect, falls, medication errors, and pressure ulcers. For three residents with allegations of abuse or neglect, investigations were incomplete, lacking resident interviews, root cause analyses, and follow-up on negative findings from other residents. In one case, a resident reported being left in urine for over an hour on multiple occasions, but the investigation did not include a direct interview with the resident or address similar concerns raised by others. Another resident reported rough handling during transfers, but the investigation only included two staff statements and did not address the lack of care plan updates regarding the resident's anxiety and fear during transfers. The facility also failed to thoroughly investigate several falls. In one instance, a resident fell out of bed and later required surgery due to hardware failure, but the fall investigation was incomplete and not updated when the extent of the injury became known. Another resident fell in the bathroom, but the investigation lacked statements from the involved staff and did not resolve conflicting information about the circumstances of the fall. For a third resident, the investigation into two falls did not include required neurological assessments or address staff concerns about inadequate help during mealtimes. Additionally, the facility did not properly investigate a medication error where a resident received a discontinued narcotic medication multiple times. The investigation failed to identify the error as a violation of professional standards and did not include education or disciplinary action for the involved nurses. There were also deficiencies in investigating a pressure ulcer incident and a delay in pain medication, including missing interviews, incomplete documentation, and failure to identify transcription errors or report incidents as required.