Failure to Complete Investigation into Alleged Neglect
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to conduct a complete and thorough investigation into an allegation of possible neglect involving a resident with heart failure and atrial fibrillation. The resident reported spilling coffee on herself, and upon assessment, was found to have scattered intact blisters on her right abdominal area, under her right breast, and upper right thigh. Although the facility's policy requires obtaining written witness statements as part of the investigation process, the facility did not secure these statements from the dining coordinator who placed the coffee on the tray or the aide who served the coffee. This omission resulted in an incomplete investigation into the incident, as required by facility policy and state regulations.