Failure to Investigate and Report Allegation of Resident Neglect
Penalty
Summary
The facility failed to investigate an allegation of neglect involving a resident who was moderately cognitively impaired and completely dependent on staff for all activities of daily living, including personal hygiene, eating, toileting, and mobility. The resident's Power of Attorney (POA) reported that the resident was left waiting for extended periods for staff assistance, and that on one occasion, the resident was improperly positioned in a mechanical lift, causing pain and distress. During this incident, the resident was forced to have a bowel movement in a garbage can while in pain and was left without proper incontinence care or safe repositioning in bed. The POA and private caregivers reported that they frequently had to provide all care, including medication administration, due to staff neglect and lack of timely response to call lights. Despite the POA's immediate report of the incident to the Interim Director of Nursing (DON) via email, there was no documented investigation into the allegation of neglect. The POA and private caregivers were not interviewed for witness statements, and the staff members involved continued to provide care to the resident after the incident. The Interim DON acknowledged receiving the complaint and stated that the staff involved reported the incident a week later, but no formal investigation was initiated, and the allegation was not reported to the State Agency as required by facility policy. The Administrator in Training (AIT) was informed of the family's concerns but deferred to the Interim DON, who indicated she was handling the situation. The facility's abuse prevention policy requires immediate investigation and notification of the Administrator for any suspected incident, but these steps were not followed. The failure to investigate and report the allegation of neglect constitutes a deficiency in the facility's response to alleged violations.