Failure to Investigate and Document Incidents of Possible Abuse or Neglect
Penalty
Summary
The facility failed to identify and investigate incidents of possible abuse and/or neglect for three residents. For one resident with hypertension, diabetes, and hyperlipidemia, abrasions were noted on the right toes after the foot was dragged on the carpet while being pushed in a shower chair. This incident was documented in the physician's progress note, but there was no corresponding entry or investigation in the facility's incident records, and the Nursing Home Administrator confirmed that no investigation was conducted as required by policy. Another resident with diabetes, post-traumatic stress disorder, and hypotension was found attempting to leave the facility on two separate occasions, including being recovered from the front door by staff. Despite these events, no investigation was conducted. A third resident with hypertension, cancer, and hyperlipidemia was found on the first floor without the required watchmate device on their wheelchair, as ordered. The Director of Nursing was unaware of this elopement, and the incident was not documented or investigated. These failures were confirmed by facility leadership during interviews.