Failure to Investigate and Address Alleged Neglect of Incontinence Care
Penalty
Summary
The facility failed to thoroughly investigate allegations of neglect involving two residents who reported not receiving incontinence care from 5:00 AM until 1:00 PM on the same day. The residents informed a nursing assistant (NA) during lunch tray delivery, who then enlisted another NA to assist with their care. The assigned NA was observed using her personal phone at the nurses' station and rounding on other residents, while another NA stated she was directed to the dining room before completing care for her last residents and did not notify others about the outstanding incontinence care needs. Review of the facility's investigation revealed that, despite the termination of the assigned NA and the investigation being initially marked as unverified, witness and resident statements did confirm the neglect occurred.