Failure to Investigate and Report Alleged Neglect
Penalty
Summary
The facility failed to implement and follow its written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation for one resident. Specifically, the facility did not investigate or report an allegation of neglect to the Texas Health and Human Services Commission (HHSC) as required by its own policy. The incident involved a family member alleging that an LVN neglected a resident, but the facility did not initiate the mandated investigation or reporting process. The resident involved was an elderly female with multiple complex medical diagnoses, including dementia, chronic kidney disease, pressure ulcer, diabetes, Parkinson's disease, and heart failure. Her care plan and physician's orders required specific wound care interventions, which were documented as being performed as ordered. Despite this, the family member expressed concerns that the LVN did not perform dressing changes as required, leading to the resident's wound worsening and subsequent hospitalization. The family member communicated these concerns to the facility's Marketer, who then reported them to the Administrator. Interviews with facility staff revealed that the Administrator and DON were aware of the family member's dissatisfaction and anger, particularly toward the LVN, but did not interpret the complaint as an allegation of neglect or abuse. As a result, the required investigation and reporting to the State were not initiated. The facility's policy clearly defined neglect and outlined procedures for immediate reporting and investigation, but these procedures were not followed in this instance.