Failure to Investigate Allegations of Abuse, Neglect, and Misappropriation
Penalty
Summary
The facility failed to ensure that all allegations of abuse, neglect, and misappropriation of property were thoroughly investigated and that residents were protected from further potential harm. In one instance, a nurse was reported to have documented an extra administration of a resident's oxycodone, raising concerns of possible drug diversion. Despite the resident denying receipt of an extra dose and staff reporting the incident to facility leadership, there was no evidence of a comprehensive investigation into the alleged misappropriation. The nurse in question continued to work with the resident after the incident until being suspended several days later, and there was no documentation of a thorough inquiry or protective measures taken immediately following the allegation. Another resident experienced an alleged incident of neglect when the same nurse failed to administer requested pain medication. The resident and her family reported that the nurse refused to provide the medication, acted in a verbally aggressive manner, and displayed erratic behavior. Documentation revealed that the pain medication was not signed out as administered, and there was no evidence that a pain assessment was completed or that the medication administration record was reviewed to verify the omission. The investigation into this incident was incomplete, lacking attempts to determine the reason for the alleged omission or to fully assess the resident's condition at the time. Interviews with facility staff, including the DON and Administrator, revealed confusion and lack of clarity regarding responsibility for conducting thorough investigations into these allegations. The facility's own policy required comprehensive investigations of all abuse, neglect, and misappropriation allegations, but this was not followed in these cases. The lack of thorough investigation and immediate protective actions left residents at risk for continued abuse, neglect, and misappropriation.