Failure to Investigate Alleged Abuse/Neglect Following Resident Grievance
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse or neglect for a resident who reported being left alone in a wheelchair for six hours, resulting in extreme soreness. The resident, who had diagnoses including orthostatic hypotension, cellulitis of the left leg, dementia, malnutrition, and required assistance with personal care, filed a grievance stating they were left unattended from 1:00 PM to 7:00 PM. The grievance was documented and addressed by a Licensed Practical Nurse and marked as resolved by the Administrator, but there was no evidence of a formal investigation into the allegation as required by facility policy. Record review showed no documentation in the resident's progress notes regarding the grievance or any investigation on the relevant dates. Interviews with facility staff confirmed that such a report should have been escalated and investigated as a potential abuse or neglect case. Despite requests for further documentation, no additional information was provided to demonstrate that an investigation took place, indicating a failure to follow the facility's abuse prevention and investigation policy.