Failure to Thoroughly Investigate Allegation of Resident Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving one resident who reported being left naked and without a gown by a CNA during a night shift. The resident, who was cognitively intact and able to make their own healthcare decisions, required assistance with dressing and reported that after using a bedpan, their gown became soiled and was removed by the CNA, who then left the resident exposed and did not return. The resident used a phone to call for assistance instead of the call light, citing previous delays in staff response, and was eventually assisted by an RN with a clean gown several hours later. The facility's investigation into the incident was incomplete. The investigation did not include an interview or statement from the RN who assisted the resident, nor did it address why the resident used a phone instead of the call light. Additionally, the investigation failed to determine how long the resident was left without a gown or whether the resident was still exposed when the RN arrived. The education provided to staff following the incident did not cover customer service or dignity issues raised in the resident's grievance and was not provided to all staff who worked during the shift in question. Interviews with other residents revealed additional concerns about staff behavior, including rudeness, rushing care, and not respecting resident preferences, such as leaving lights on at night. The Nursing Home Administrator acknowledged that the concerns regarding the CNA constituted neglect and confirmed that the CNA was no longer employed at the facility. However, the investigation documentation lacked key details and did not fully address the scope of the resident's allegations or the related staff conduct.