Incomplete Investigation of Abuse/Neglect Allegation
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into an allegation of potential abuse/neglect involving a resident with multiple medical conditions, including diabetes, hypertension, a pressure ulcer on the left hip, and heart failure. The resident reported that a nurse aide shoved a bed pan under him, causing severe pain to his pressure ulcer, and delayed providing care after the resident had a bowel movement. The incident was reported to the State Survey Agency, and the facility initiated an investigation. However, the investigation was incomplete. The statement obtained from the accused nurse aide did not address the specific allegations made by the resident, and there was no evidence that the facility questioned the aide about the incident. Additionally, although two licensed nurses provided witness statements, four other staff members who were present during the shift were not interviewed, and there was no documentation of their input. The lack of comprehensive staff interviews and failure to address the resident's specific allegations resulted in an incomplete investigation.