Failure to Investigate Alleged Neglect After Resident Fall
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into an allegation of neglect involving one resident. According to facility policy, all events involving evidence of abuse or neglect should be thoroughly investigated, including obtaining statements from all potential persons who might have had contact with the resident within the relevant timeframe. However, when a resident was found on the bathroom floor after attempting to call for help and not receiving a response, no incident report or investigation was initiated by the facility. The Director of Nursing confirmed that there was no documentation or investigation available regarding the resident's allegation that staff did not respond to their request for assistance, which led to the resident attempting to ambulate independently and subsequently falling. The resident involved had a history of arthritis, polyosteoarthritis, and muscle weakness, and required supervision or assistance for walking and toilet transfers. The resident was identified as being at risk for falls due to pain with movement and osteoarthritis, and used both a walker and wheelchair for mobility. Despite these documented needs and risks, the facility did not follow its own policy to investigate the circumstances surrounding the resident's fall and the alleged lack of staff response, resulting in a failure to rule out neglect.