Failure to Conduct Thorough Investigations into Allegations of Neglect and Abuse
Penalty
Summary
Facility staff failed to conduct a thorough investigation into two separate allegations of neglect and possible abuse involving two residents. In the first case, a resident with severe dementia was presumed to have ingested a body wash, resulting in hospitalization for acute hypoxic and hypercapnic respiratory failure. Multiple staff members observed symptoms consistent with soap ingestion, such as foaming at the mouth, pink-tinged bubbles, and respiratory distress. Despite these observations and statements from several staff and the resident's roommate, the facility's internal investigation was limited to interviews with only two staff members and a review of hospital records. The facility concluded the incident was unsubstantiated due to lack of direct witness, despite substantial circumstantial evidence and staff testimony indicating otherwise. In the second case, the facility failed to thoroughly investigate an allegation of neglect regarding timely incontinent care for another resident. The resident's daughter reported that her father had not been changed for an extended period, and staff witness statements, as well as photographic evidence, confirmed the resident was found in a wet brief that had been marked earlier in the day. Staff interviews revealed inconsistencies in care documentation and a lack of timely intervention. The administrator, who also served as the abuse coordinator, acknowledged the situation but did not conduct a comprehensive investigation, relying instead on limited staff interviews and dismissing the daughter's concerns. Both incidents demonstrate a failure by facility staff to follow their own abuse and neglect investigation policies, which require immediate and thorough internal investigations, including collecting evidence and interviewing all relevant witnesses. The lack of comprehensive investigations in both cases was directly observed and documented by surveyors, who noted that the facility did not meet its own standards for responding to allegations of abuse and neglect.