Failure to Investigate Allegation of Neglect Related to Colostomy Care
Penalty
Summary
The facility failed to fully investigate an allegation of neglect involving a resident with a colostomy. The resident, who was cognitively intact and had diagnoses including diverticulitis, colostomy, and muscle weakness, reported that an LPN removed his colostomy bag, discarded it, and when unable to find a replacement, retrieved the soiled bag from the garbage, cleaned it with bleach and mouthwash, and reapplied it. The resident stated this did not cause pain or discomfort but made him feel nervous. The LPN confirmed she did not seek assistance or look for the correct supplies and used mouthwash and bleach to clean the soiled bag before reapplying it. Despite the resident's grievance, the facility did not document an investigation into the neglect concern in the progress notes or submit a report indicating an investigation was completed. The Director of Nursing confirmed that the incident was not recognized as neglect, no investigation was conducted, and no witness statements were obtained from the resident, other residents, or staff members. This failure to investigate was not in accordance with the facility's policy, which requires prompt and thorough investigation of all abuse and neglect allegations.