Failure to Conduct Thorough Investigation of Neglect Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of neglect involving a resident who required staff assistance with personal hygiene and toileting due to orthopedic aftercare, muscle weakness, and an ADL self-care performance deficit. The incident occurred when a nurse aide refused to assist the resident with hygiene after toileting, despite the resident's inability to clean herself properly due to swollen legs. The resident, her roommate, and several staff members confirmed that the aide told the resident to clean herself and subsequently left the room, after which another aide was assigned to provide care. Following the incident, the facility initiated an investigation as required by policy, which mandates obtaining statements from all staff members who had contact with the resident during the period of the alleged incident. However, the investigation was incomplete, as written statements were not obtained from all relevant staff, including the social services assistant, a licensed nurse who interacted with the resident immediately after the incident, and the nurse aide who provided care following the event. The nursing supervisor and the Director of Nursing both confirmed that these statements were not collected, despite their involvement or presence during the incident. The deficiency was identified through review of facility policies, documentation, clinical records, and interviews with residents and staff. The failure to obtain comprehensive witness statements from all involved parties resulted in an incomplete investigation of the neglect allegation, contrary to the facility's own policies and regulatory requirements.