Failure to Identify and Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to identify and investigate allegations of abuse and neglect for four out of seven sampled residents. For one resident with a history of peritoneal abscess, ovarian cancer, muscle weakness, anxiety, and depression, there were repeated delays or omissions in administering PRN pain medication by an LPN, despite the resident communicating their needs to both CNAs and a nurse supervisor. The medication administration record showed a lack of timely pain medication administration during specific shifts, and the issue was not reported or investigated as required by facility policy. Another resident with bipolar disorder and borderline personality disorder reported being touched by another resident during an activity, which caused distress and led to withdrawal from activities. The incident was reported to the activity director, who spoke to the other resident but did not document the event or report it as required. There was no record of the incident in the grievance or incident logs, and the required investigation was not initiated. Additional concerns involved a resident with adjustment disorder and anxiety who reported fear and perceived retaliation from the administrator after filing a grievance, leading to self-isolation. Another resident with COPD and depression described the administrator as rude and avoided interactions. Multiple residents expressed concerns about the administrator's behavior, but these were not logged or investigated as potential abuse or neglect. The facility's failure to identify, document, and investigate these allegations did not meet the expectations outlined in their abuse and neglect policy.