Failure to Conduct Thorough Investigations of Alleged Violations
Penalty
Summary
Facility staff failed to conduct thorough investigations into alleged violations involving two residents. In the first case, an email complaint was received by the Administrator and DON detailing concerns about a resident's care, including issues with medications, oxygen, nutrition, hydration, hygiene, and personal care. The investigation file was missing the original complaint email, and when it was later provided, it was found that not all concerns listed by the complainant were addressed in the facility's investigation. Documentation showed significant gaps in incontinence care, with records indicating the resident may have gone over 12 hours without being changed on multiple occasions. The facility was unable to provide additional documentation to confirm that care was provided more frequently than recorded, and did not investigate all concerns raised, such as those related to medication and oxygen. In the second case, a resident reported to the Social Service Director that a GNA was verbally aggressive during a specific shift. The investigation file indicated that interviews were conducted, but there was no documentation of these interviews except for the alleged perpetrator. Staff and resident questionnaires were used, but responses indicating possible abuse were not followed up as required. The resident involved, who is legally blind, described a delay in assistance and reported being verbally abused by the GNA, with a roommate present as a witness. The facility's investigation did not include documented interviews with all relevant staff, witnesses, or the alleged victim, and the Administrator acknowledged that interviews were not properly documented. In both cases, the facility's investigations were incomplete, lacking documentation and follow-up on all allegations and failing to address all concerns raised by complainants. The absence of thorough documentation and failure to investigate all aspects of the complaints led to inconclusive findings and unaddressed allegations regarding resident care and staff conduct.