Failure to Thoroughly Investigate Allegations of Neglect and Misappropriation
Penalty
Summary
Surveyors found that the facility failed to thoroughly investigate multiple allegations of neglect and misappropriation involving seven residents. These allegations included residents not being changed for extended periods, long wait times for call light responses, and a report of possible misappropriation of resident property. In each case, the facility did not obtain staff statements or interview other residents to determine if there was a pattern of neglect or if other residents were affected. The facility's own policies require thorough investigation and reporting of such allegations, but these procedures were not followed. Specific incidents included residents reporting not being changed for hours, having to wait until the next shift for assistance, and being left in soiled conditions overnight. In one case, a resident's representative reported that the resident was not cleaned up after a bowel movement until late in the morning, with staff citing being too busy. Another resident's representative reported that a CNA told the resident they could not help at that time, resulting in a long wait for assistance. In the case of alleged misappropriation, the investigation was limited to brief observations and informal conversations, without formal staff interviews or broader resident interviews to assess the scope of the issue. Interviews with facility staff, including the Life Coach and Director of Nursing, revealed a lack of clarity and consistency in the investigation process. Staff members were sometimes unsure of their roles or the definitions of neglect and abuse, and in some cases, the person assigned to investigate did not actually conduct the investigation. Documentation was incomplete, and there was no evidence that the facility took steps to determine if other residents were affected by the same staff members implicated in the allegations.