Failure to Investigate Alleged Neglect in Pain Management
Penalty
Summary
The facility failed to fully investigate a potential allegation of neglect involving a resident who was cognitively intact and required supervision for functional tasks. According to the grievance, the resident requested Tylenol for pain from the night nurse, who refused to provide it, stating she did not believe the resident was in pain. The nurse did not offer any alternative interventions, and the resident waited until the next shift to request pain relief, at which point the pain was assessed as severe (8 out of 10) and medication was administered. The medical record and MAR confirmed that no pain medication was given by the night nurse, and there was no documented pain assessment or nursing note for that shift. The facility's policies require immediate and thorough investigation of any allegations or suspicions of neglect, including timely interviews with all involved parties and documentation of findings. In this case, the grievance was written by a staff member, but there was no indication that the staff member who reported the concern was interviewed. The nurse implicated in the grievance provided a written statement two weeks after the incident, which was not timely. The Director of Nursing acknowledged that the nurse did not adequately manage the resident's pain and that the incident should have been investigated as potential neglect, rather than being handled solely as a grievance. Additionally, the resident was sent to the hospital a week after the incident, though the report does not link this directly to the pain management issue. The Director of Nursing could not recall seeing that the medication was not given at the time and confirmed that the investigation was incomplete. The facility did not follow its own policies for investigating allegations of neglect, resulting in a failure to respond appropriately to the alleged violation.