Failure to Investigate Resident Neglect After Unattended Medical Appointment
Penalty
Summary
The facility failed to thoroughly investigate an incident in which a resident with severe cognitive impairment and a known risk for elopement was left unattended during an outside medical appointment. The resident, who had a diagnosis of dementia and heart failure, was accompanied to a cardiology appointment by a nurse aide. After the appointment, the nurse aide left the resident alone in a lobby area while she used the restroom. During this time, the resident was observed by a transportation driver and another individual attempting to leave the facility, and was stopped outside by a driver who questioned her about her caregiver's whereabouts. Upon returning to the facility, the nurse aide verbally reported the incident to an LPN, who provided immediate education to the aide and wrote a witness statement, which was then given to an RN Supervisor. However, the RN Supervisor did not report the incident to the Nursing Home Administrator or the Director of Nursing, believing the information to be a rumor. The transportation driver, who also witnessed the incident, informed the RN Supervisor but did not escalate the report to facility administration. As a result, the facility did not follow its written abuse policy, which requires immediate reporting and investigation of any allegations of abuse or neglect. The administration was not made aware of the incident until it was discovered during a survey investigation. No immediate investigation was initiated, and statements from all involved parties were not collected as required by policy and federal regulations.