Failure to Investigate Allegations of Neglect for Multiple Residents
Penalty
Summary
The facility failed to fully investigate allegations of neglect for four residents who were incontinent and dependent on staff for care. According to the facility's own policy, an investigation into any allegation of abuse or neglect should be initiated within 24 hours, including a clinical examination for injuries, assessment of causative factors, and implementation of interventions to prevent further harm. However, after a grievance was filed by staff noting that four residents were found in soaked briefs and unchanged clothing at the start of a shift, the facility did not conduct a thorough investigation. The residents involved had significant cognitive impairments and were frequently or always incontinent, as documented in their clinical records and Minimum Data Set (MDS) assessments. Despite the grievance indicating that the responsible nurse aide was from an agency and would not be allowed to return, the facility did not document any investigation into whether the supervising licensed nurse had concerns about the aide's performance, whether other residents assigned to the aide received appropriate care, or whether skin checks were completed to assess for injuries related to prolonged exposure to soiled briefs. The Director of Nursing and Administrator in Training confirmed that no such investigation was completed, resulting in a failure to respond appropriately to the alleged neglect as required by facility policy and state regulations.