Failure to Thoroughly Investigate Allegation of Resident Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident who was reported by his sister to have left for a medical appointment in an unclean state, with unchanged socks and inadequate hygiene. Although the facility promptly reported the incident and collected statements from staff and the resident, they did not verify the allegation beyond these internal accounts. The investigation did not include contacting the ambulance company that transported the resident or the healthcare facility where the appointment took place, despite the sister's previous complaints and the external facility's subsequent report to the survey agency. Upon review, it was found that when the resident arrived at the outside healthcare facility, staff there observed that he smelled strongly of urine, and his socks and clothing were soiled and adhered to his feet. The facility's social workers and the Nursing Home Administrator confirmed that they had not reached out to the ambulance company or obtained the external facility's consult until prompted by the surveyor. The resident was known to have frequent incontinence and refused to wear briefs, a fact acknowledged by both staff and his sister, but this information was not adequately incorporated into the investigation process.