Failure to Thoroughly Investigate Alleged Mistreatment and Neglect
Penalty
Summary
Facility staff failed to thoroughly investigate a behavioral incident involving a resident with multiple complex medical conditions, including cerebral infarction, diabetes, hypertension, and psychiatric diagnoses. The incident involved a verbal altercation between the resident and staff, during which the resident alleged that staff did not provide assistance after he spilled urine on himself. The resident reported feeling that his rights had been violated and that he was not assisted as requested. The facility's investigation focused primarily on the resident's subsequent verbal aggression and threats toward staff, which led to law enforcement being contacted and the resident being assessed by a psychiatric nurse practitioner. The investigation included statements from several staff members who witnessed or were involved in the incident, but it did not include a statement from the certified nurse aide assigned to the resident at the time of the alleged neglect. Additionally, the investigation did not address the resident's specific allegation that assistance was not provided, nor did it include interviews with other residents who may have witnessed or overheard the incident. The facility's policy requires a thorough investigation of all reports of abuse, neglect, or mistreatment, including interviews with all relevant staff and witnesses, but this was not fully carried out in this case. The deficiency was identified during a review of facility documentation, staff interviews, and clinical records, which revealed gaps in the investigation process. The administrator and regional nurse consultant were unable to provide documentation that the resident's allegation of not receiving assistance was investigated, and the assigned CNA confirmed she had not been interviewed about the incident prior to the survey. The lack of a comprehensive investigation into the resident's allegation of neglect and potential mistreatment constituted a failure to respond appropriately to all alleged violations.