Failure to Complete and Submit Abuse/Neglect Investigations for Two Residents
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to complete and submit thorough abuse/neglect investigations for two residents after receiving allegations from their representatives. For the first resident, who had been admitted and later discharged home, the State Agency (SA) received an intake alleging that between 2:00 AM and 3:00 AM the resident activated the call light for urgent medical assistance, staff did not respond in a timely manner, and the resident remained unattended while in acute physical distress, including vomiting, which she later reported to her representative. The facility interviewed the resident, who did not recall the time she vomited, and staff were interviewed about events on and around the alleged date. However, when surveyors and the SA requested a completed investigation, the facility only produced staff witness statements and did not provide a written investigative summary or other required documentation. For the second resident, who had been admitted and later transferred to the hospital, the SA received an intake alleging that the resident’s catheter was clogged and that staff pushed the resident into the lobby for discharge so a new admission could use the room; the representative canceled the discharge and arranged for hospital transfer. Facility staff reported that the DON/designee reviewed catheter care notes and that an administrator reviewed video footage of the discharge and documented a brief note, and two nurses were contacted for their recollection of events. Despite these steps, the facility again failed to provide a completed investigation to the SA or onsite surveyors, supplying only staff witness statements. Interviews with the Administrative Nurse and Administrative Staff revealed that each assumed the other had submitted the completed investigations, and no written summary consistent with the facility’s abuse policy—requiring a completed investigation with a written summary of findings within five working days—was produced for either allegation.
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