Failure to Thoroughly Investigate Allegation of Neglect
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate an allegation of neglect involving a female resident with Alzheimer's disease, a gastrostomy tube, and adult failure to thrive. The resident was dependent on staff for all activities of daily living and was always incontinent of bladder and bowel. A family member found the resident sitting in urine and feces with dirty bedding and reported this to staff. The nurse on duty was unable to locate the assigned aide, who was later found to be on break, and another aide was called to change the resident. The facility administrator was notified of the allegation via email and initiated an investigation, which included checking on the resident and having clinical staff perform a skin assessment. The administrator reported the incident to the state and attempted to contact the agency and the assigned CNA, but was unsuccessful. The administrator did not contact the nurse who was on shift or the aide who changed the resident. The DON also attempted to contact the nurse and CNA involved but was unsuccessful and did not contact the aide who changed the resident. The investigation did not include interviews with all individuals who had firsthand knowledge of the incident, specifically the aide who changed the resident after the family member's report. Facility policy required comprehensive investigations, including written summaries of interviews with witnesses, but this was not completed. The failure to conduct a thorough investigation was confirmed by both the administrator and DON, who acknowledged that key staff were not interviewed.