Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to properly investigate and respond to allegations of abuse and neglect for two residents, as required by its own policies. In the first case, a resident with bipolar disorder, morbid obesity, and chronic congestive heart failure, who was cognitively impaired and dependent on staff for care, reported that a nurse aide was frequently in a bad mood, made dismissive comments such as 'This is just a job,' and made remarks about the resident's weight. The grievance form documenting this complaint was not signed by the staff member who completed it, and the Director of Nursing Services (DNS) did not conduct a thorough investigation at the time, citing confusion over the resident's desire for anonymity and not interviewing all involved parties or addressing all aspects of the complaint, such as the weight-related comments. In the second case, a resident with dementia, muscle weakness, and incontinence was found by a responsible party to be in a very soiled and odorous brief late in the morning. The grievance form indicated that staff would be re-educated on toileting rounds, but there was no evidence of an investigation or staff education being conducted. The DNS was unaware of the grievance and could not locate any documentation of follow-up or investigation. The staff members involved in the original grievance process were no longer employed at the facility, and no further information was available in the resident's records regarding the incident. Both incidents demonstrate that the facility did not follow its own grievance and abuse prohibition policies, which require immediate reporting and thorough investigation of any potential abuse or neglect. The lack of proper documentation, failure to interview all relevant parties, and absence of timely investigations contributed to the deficiencies identified by surveyors.