Failure to Conduct Thorough Investigation of Neglect Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident with a foley catheter. The Nursing Home Administrator (NHA) became aware of the allegation when a Department of Children and Families (DCF) agent arrived and reported that the resident's family alleged the facility did not replace the resident's foley catheter or provide catheter care, which they believed led to an infection. The NHA did not contact the family for further information and was unsure about the details of the catheter order. The investigation did not include contacting the resident's urologist, and the NHA was unaware of the resident's complaints of severe pain that began several days before the resident was sent to the emergency room. The NHA stated that interviews were conducted with some staff, but could not provide records of these interviews, and did not interview all relevant staff involved in the resident's care. Additionally, the facility did not obtain hospital records related to the resident's care, citing difficulty in obtaining them, and was unaware of the presence of a perineal wound and an unstageable pressure injury where the foley catheter would lay. The Senior Regional Nurse Consultant (SRNC) was the only attendee aware of the hospital report indicating gangrene. The facility's own policy required a complete and thorough investigation, including interviews with all relevant parties and review of documentation, but these steps were not fully completed in this case.