Failure to Investigate Alleged Abuse and Neglect Incidents
Penalty
Summary
The facility failed to conduct thorough investigations into incidents involving two residents, as required by its abuse policy and state regulations. For one resident with Alzheimer's Disease and dementia, a grievance was filed by her daughter after a male resident was found in her bed and was only removed after the roommate called for staff assistance for several minutes. There was no documentation of the incident in the resident's medical records, nor any evidence that an investigation was completed to determine if neglect or abuse had occurred. In a separate incident, another resident who was cognitively intact and dependent on staff for care sustained a skin tear. Although the Director of Nursing heard a noise and checked on the resident, there was no documented investigation to rule out neglect or abuse. Interviews with facility leadership confirmed that written statements were not obtained from staff or residents involved, and no formal investigation was conducted for either incident.