Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to conduct complete and thorough investigations into allegations of abuse and neglect for six residents. Facility policy required staff to prevent, report, and investigate suspected or alleged abuse, neglect, or mistreatment, with specific steps for interviewing involved parties and documenting findings. However, in multiple cases, the facility did not follow these procedures, resulting in incomplete investigations and lack of proper documentation. For one resident with hemiplegia and incontinence, a family member reported neglect due to delayed incontinence care. The facility's documentation confirmed the delay but did not provide a complete investigation or documentation of the incident. Another resident, who was severely cognitively impaired and on hospice care, was found saturated in urine by a hospice nurse, but the facility did not document a thorough investigation or report the incident to the Department of Health as required. In another case, a cognitively intact resident was observed being handled roughly by a nurse aide, but the facility's report omitted key details of the incident. Additional deficiencies included a resident reporting rough handling, being hit, denied a snack, and experiencing verbal abuse from a nursing assistant. The facility did not investigate or document these allegations. Another resident reported being grabbed and thrown by a nurse, but there was no evidence that the facility interviewed other staff or residents as part of the investigation. These failures to investigate and document allegations of abuse and neglect were confirmed through interviews with facility leadership and staff, as well as review of facility records.