Failure to Thoroughly Investigate Neglect Allegation Related to Wound Care
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect related to wound care for a resident with multiple medical conditions, including a wedge compression fracture, diabetes, bacteremia, and a history of falls. The resident had an indwelling catheter and an unstageable pressure ulcer, and was discharged to the hospital after experiencing profuse bleeding. The facility's investigation into the neglect allegation included a review of the resident's diagnosis, a skin check evaluation, a previous hospitalization, and interviews with other residents regarding neglect. However, the investigation did not include interviews with staff directly involved in the resident's care, nor did it review records related to the resident's wounds or the care provided for those wounds. Additionally, the investigation lacked documentation explaining the circumstances surrounding the resident's wounds and did not identify procedures to prevent similar occurrences in the future. When questioned, the Administrator stated that a thorough investigation had been conducted, but was unable to provide information regarding the resident's wounds or the connection to the neglect allegation. The only staff interview conducted was with a nurse supervisor present during the resident's transfer to the hospital, and there was no evidence of a comprehensive review of wound care practices or staff actions related to the incident.