Failure to Investigate Incidents and Complete Staff Background Checks
Penalty
Summary
The facility failed to implement and follow its own written policies and procedures regarding the prevention, identification, and investigation of abuse, neglect, and misappropriation of resident property. Specifically, the facility did not conduct a complete and thorough investigation of incidents involving two residents. One resident sustained abrasions to the toes after their right foot was dragged on the carpet while being pushed in a shower chair, but this incident was not documented or investigated as required by facility policy. Another resident, who had diagnoses including hypertension, cancer, and hyperlipidemia, was found on a different floor without their required monitoring device, indicating a potential elopement. This incident was also not documented or investigated, and the DON was unaware of the event. Additionally, the facility failed to conduct required state criminal background checks prior to the start of employment for two nursing staff members, an LPN and an RN. Personnel records for both staff members did not include completed background checks before their hire dates, contrary to facility policy and regulatory requirements. The Human Resources staff and the Nursing Home Administrator confirmed that these checks should have been completed prior to employment but were not. These deficiencies were identified through a review of facility documents, policies, clinical records, and staff interviews. The facility's failure to follow its own policies and regulatory requirements resulted in uninvestigated incidents involving potential neglect and incomplete staff background screening.