Failure to Investigate and Respond to Alleged Neglect of Tracheostomy Care
Penalty
Summary
The facility failed to investigate an allegation of neglect involving a resident who was dependent on staff for tracheostomy care. The resident reported that an LPN frequently refused or delayed providing suctioning, despite having physician orders for deep suctioning as needed every 20 minutes. The resident described having to activate the call light multiple times and rely on CNAs to communicate his needs to the LPN, resulting in significant anxiety and feelings of neglect. Multiple CNAs corroborated the resident's account, stating that the LPN routinely refused to suction the resident's tracheostomy when requested, and that these concerns were reported to the DON both verbally and via text message. Despite these reports, there was no evidence that the facility conducted a thorough investigation into the allegations. Documentation and interviews revealed that the DON was made aware of the situation through staff communications, including text messages and phone calls, but did not initiate a formal investigation or separate the LPN from the resident during the period in question. The DON acknowledged receiving concerns about the frequency of suctioning and the LPN's response but did not document any follow-up actions or witness statements related to the alleged neglect. The clinical record lacked documentation of the suctioning order being utilized by the LPN, and there was no evidence of a comprehensive review of the resident's care or staff performance regarding the allegations. The resident involved had a history of acute and chronic respiratory failure with hypoxia, functional quadriplegia, and a tracheostomy, making timely and appropriate suctioning critical to his well-being. The failure to respond appropriately to the resident's needs and to staff reports of neglect constituted a deficiency in the facility's abuse prevention, identification, and investigation procedures. The facility's policy required immediate notification, investigation, and documentation of alleged abuse or neglect, but these steps were not followed in this case.