Failure to Thoroughly Investigate Alleged Abuse/Neglect Incident
Penalty
Summary
The facility failed to provide evidence of a thorough investigation into an allegation of abuse/neglect involving a resident with hemiplegia, morbid obesity, and atherosclerosis. The resident reported falling to the ground while being transferred from bed to wheelchair using a Hoyer lift by a nurse aide. The incident was not immediately reported by the staff involved, and the resident only disclosed the fall later due to ongoing pain and after learning the aide had resigned. Documentation showed that the resident described the fall and the aide's request to keep the incident quiet, fearing job loss. The facility's investigation records were incomplete, lacking evidence that the alleged perpetrator (the nurse aide) was contacted or interviewed. There was also no documentation of attempts to interview other licensed nurses, nurse aides across relevant shifts, or other residents who may have been under the care of the involved aide. The investigation section of the grievance form was left incomplete, and the date of completion was not recorded. These omissions indicate that the facility did not follow its abuse prevention policy or ensure a comprehensive investigation into the reported incident.