Failure to Investigate and Address Alleged Delay in Incontinence Care
Penalty
Summary
The facility failed to conduct a thorough investigation and did not take necessary steps to address an alleged violation regarding a resident's care. A resident, who was classified as dependent and had decision-making capacity, reported waiting three hours for incontinence care. The facility's investigation concluded the allegation was unsubstantiated. However, documentation included a corroborating statement from the resident's roommate, who also had capacity, confirming that the resident experienced extended wait times for assistance on multiple occasions, including the night in question. Additionally, a physical therapist documented that the resident reported repeated requests for assistance over the weekend that were not fulfilled by nursing assistants. Review of toileting logs showed significant gaps between care episodes, with the resident receiving assistance at widely spaced intervals, supporting the claim of delayed care. The roommate further stated that the resident was often ignored and eventually moved to another facility by her family. These findings indicate that the facility did not adequately respond to or investigate the alleged violation, as required.