Failure to Thoroughly Investigate Alleged Neglect After Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate an allegation of potential neglect involving a resident who fell during a shower provided by a CNA. The resident, who had diagnoses including autism, long-term use of anticoagulants, central pain syndrome, gait and mobility abnormalities, contracture of the left hand, and general muscle weakness, required the assistance of two staff for transfers, pericare, and showers according to the care plan. During the incident, the CNA did not follow the care plan, resulting in the resident standing alone in the shower, falling, and sustaining a head and left shoulder abrasion. The facility's investigation was incomplete, lacking documentation of resident interviews that were reportedly conducted, and failing to include which residents were interviewed. Additionally, not all nursing staff received the required education on following care plans, as evidenced by missing signatures on education sign-in sheets and confirmation from the DON that some staff who had worked since the incident had not yet been educated. These actions and omissions did not meet the facility's policy requirements for a systematic and thorough investigation of alleged neglect.