Failure to Investigate Allegation of Neglect
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate an allegation of neglect involving a resident with chronic osteomyelitis and a diaphragmatic hernia. The resident, who required assistance with activities of daily living and was incontinent, reported calling for help after a bowel movement and not receiving assistance for five hours, despite multiple requests. The resident's grievance was documented, but the investigation process was incomplete. Key facility staff, including the Director of Nursing Services (DNS), social worker, and administrator, were responsible for investigating such allegations. However, the DNS was unaware of the incident, and the administrator could not provide documentation of a completed investigation, including staff or resident statements or a summary of findings. The administrator also could not identify the staff involved or explain why the DNS was not included in the investigation. Staff members who worked during the incident were not interviewed as part of the investigation, nor were they removed from the schedule pending the outcome, as required by facility policy. Interviews with staff assigned to the resident on the day of the incident revealed that they were not informed of the allegation, were not asked to provide statements, and did not receive any education related to the event. The facility's policy required immediate reporting and thorough investigation of all allegations of neglect, including removal of the alleged abuser from resident care, but these steps were not followed. Attempts to interview additional staff involved were unsuccessful.