Incomplete Investigation of Alleged Resident Neglect
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into an allegation of potential abuse/neglect involving a resident with multiple complex medical conditions, including hypertension, cerebral infarction, cognitive communication deficit, end stage renal disease, and dependence on renal dialysis. The incident in question involved the resident contacting his wife to report that he needed assistance with changing, but staff did not respond in a timely manner, resulting in the resident being found in soiled pajamas soaked in urine and feces. The facility initiated an investigation, interviewing several staff members and the resident, but did not obtain or document critical information from the assigned nurse aide regarding whether and when she assisted the resident with toileting or changing during her shift. The investigation was ultimately deemed unsubstantiated by the facility, but review of the documentation revealed that the process was incomplete. Specifically, there was no evidence that the facility asked the assigned nurse aide about her involvement in the resident's care during the relevant shift, nor was there documentation of her actions related to the resident's toileting needs. During a subsequent interview, facility leadership could not provide evidence that this key aspect of the investigation had been addressed. This failure to conduct a comprehensive investigation was found to be out of compliance with facility policy and state regulations regarding the reporting and investigation of abuse and neglect.