Failure to Investigate Alleged Neglect of Dependent Resident
Penalty
Summary
The facility failed to investigate an allegation of abuse/neglect for a resident with multiple complex medical conditions, including multiple sclerosis, epilepsy, depression, anxiety, and overactive bladder. The resident was severely cognitively impaired, dependent on staff for activities of daily living, and required frequent incontinence care. According to a nursing assistant's written statement, the resident did not receive incontinence care until late in the shift, and this concern was reported to the supervising RN at the end of the shift. The RN supervisor submitted the statement by sliding it under the office door of the Director of Nursing Services (DNS) or Assistant Director of Nursing Services (ADNS) but did not confirm receipt. The DNS later acknowledged awareness of the allegation but was unable to provide an investigation report and indicated that the ADNS, who was covering at the time, was unavailable. Facility policy required immediate reporting and prompt investigation of abuse allegations, including removal of the alleged abuser from resident care and initiation of an investigation within 24 hours. However, there was no evidence that an investigation was conducted or that the required procedures were followed after the allegation was reported.