Failure to Conduct Thorough Abuse and Neglect Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse and neglect for two residents. For one resident with multiple sclerosis and anxiety, who was cognitively intact and experienced constant pain, the facility did not fully investigate an allegation that a nurse withheld pain medication and made derogatory comments. The investigation did not include a review of the resident's medical record to confirm medication administration times, nor did it include an interview with the nurse involved or with other residents regarding their experiences with medication administration or verbal abuse. The investigation summary instead focused on the resident's history of making allegations and ruled out abuse and neglect without substantiating the facts. For another resident with demyelination of the central nervous system, anxiety, and depression, who was dependent on staff for toileting and preferred female caregivers, the facility did not thoroughly investigate an allegation of neglect after the resident waited over an hour and a half for incontinence care. The investigation acknowledged the delay but did not identify it as potential neglect, nor did it assess whether other residents with similar care preferences were at risk. The investigation also failed to interview another resident who preferred female caregivers to determine if their needs were unmet. Interviews with facility leadership revealed a lack of awareness regarding key documentation and investigative steps, such as not reviewing relevant progress notes or interviewing involved staff. The Director of Nursing confirmed that essential investigative actions were omitted, including not checking medication administration times and not interviewing other potentially affected residents. The facility's investigations did not meet the minimum requirements outlined in their own abuse prevention policy, which mandates interviews with alleged perpetrators and thorough record reviews.