Failure to Thoroughly Investigate Multiple Abuse and Neglect Allegations
Penalty
Summary
The facility failed to conduct complete and thorough investigations into multiple reported allegations of abuse and neglect. For one resident with ALS, intact cognition, and total dependence on staff for all ADLs, a grievance was filed after the resident reported that an LPN did not respond to their request to have their glasses put on, instead holding the glasses out silently for several minutes, then placing them down and leaving the room without assisting or explaining. The resident reported feeling unsupported and mistreated and requested that this staff member no longer enter their room or provide care. Although the concern was reported to the DNS, the investigation as documented focused on educating the staff member, without evidence of a root cause analysis, contributing factors review, or measures to rule out abuse or neglect. For another resident with dementia, heart failure, urge incontinence, intact cognition, and frequent urinary incontinence, the resident’s representative reported finding the resident with dried toothpaste on their face, shirt, and pants and with a brief so saturated with urine that it leaked down the hallway when the representative assisted the resident to the day room. The grievance documentation showed the resident was interviewed and reported no concerns, and the DNS concluded that lack of dignity and timely care could not be substantiated and that abuse and neglect were ruled out. However, the grievance file contained no interviews with other residents, no identification of the staff involved in the incident, no staff statements, no care plan changes, no alert charting, and no skin checks to assess the resident after sitting in urine. The investigation lacked any documented root cause or analysis explaining why the resident was soaked with urine or why personal hygiene needs were not met. For a third resident with heart failure, lung disease, intact cognition, and frequent urinary incontinence, a grievance was filed after the resident reported that a nursing assistant entered their room and told them to stop locking the “dang” door, blaming them for locking a shared bathroom door. The resident reported being upset by the unprofessional tone, feeling as if they were being scolded and accused of lying when they tried to explain they had not used the restroom that day, and described the staff member throwing their hands up and leaving the room while the resident was talking. The grievance conclusion documented removal of the staff member from the room and unit and referenced education about sharing information on other residents, but there was no documented root cause or analysis to rule out abuse or neglect, no interviews with other residents about the staff member’s interactions, no care plan changes, and no alert charting to monitor for adverse reactions. Additionally, the facility’s reporting incident log contained no entries for these allegations, and the administrator and DNS acknowledged staff confusion about what should be entered on the grievance log versus the reporting log.
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