Failure to Investigate and Report Alleged Neglect and Injury
Penalty
Summary
The facility failed to thoroughly investigate potential allegations of neglect for two residents. In the first case, a resident with severe cognitive impairment and multiple respiratory diagnoses tested positive for COVID-19 and subsequently developed new and worsening respiratory symptoms over several days. Despite these changes, the provider was not notified until the resident was found unresponsive and required emergency hospitalization. Following this event, the resident's Power of Attorney (POA) filed a complaint alleging neglect, specifically citing concerns that staff did not act on declining oxygen saturation until the resident became unconscious and that the resident was not adequately monitored. The facility did not initiate a thorough investigation into the allegation of neglect, nor did it report the incident to the State agency as required by policy. In the second case, another resident with moderate cognitive impairment, mobility limitations, and a history of falls experienced an unwitnessed fall resulting in a nondisplaced humerus fracture. The incident was discovered by a nurse, and the resident was transferred to the emergency room for evaluation. Although the interdisciplinary team reviewed the fall and implemented new interventions, the root cause of the fall was not clearly identified, and there was no documentation of staff or resident interviews or staff education to prevent future incidents. The incident was not reported to the State agency, and no misconduct report was initiated. In both cases, the facility's actions did not align with its own policy, which requires immediate reporting and thorough investigation of all alleged violations involving neglect. The Director of Nursing acknowledged during interviews that these incidents should have been considered potential neglect and reported accordingly, but this was not done.