Failure to Prevent and Document Resident Neglect
Penalty
Summary
The facility failed to protect residents from neglect and ensure proper care, as evidenced by multiple substantiated incidents. One resident, who was alert and oriented but lacked capacity for medical decisions, reported that CNAs instructed her to soil her brief instead of assisting her to the toilet, despite her ability to walk to the bathroom with assistance. This allegation was substantiated through resident interviews, although the specific staff member involved could not be identified due to lack of recall by the resident. Another incident involved a resident with Alzheimer's disease and dementia who sustained a fall that was not documented in the medical record. There was no evidence of neuro-checks, treatment, or follow-up after the fall, and the nurse on duty at the time resigned and did not provide a statement. The resident later returned to the facility with a spinal brace and was receiving intravenous antibiotics for a hip infection. The fall and lack of documentation were confirmed by both a CNA and the resident's roommate, who is alert and oriented. A third resident was also found to have experienced neglect, as verified by the facility's investigation. The facility's own Abuse Prohibition Policy requires immediate reporting and thorough documentation of suspected abuse or neglect, but these procedures were not followed in the cases described. The deficiencies were substantiated through interviews, record reviews, and facility investigations.