Failure to Investigate and Report Multiple Allegations of Neglect and Abuse
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and report multiple allegations of neglect and abuse, as required by its abuse prohibition policy. One cognitively intact resident with severe morbid obesity, cervical disc degeneration, muscle wasting, depression, and anxiety alleged that she received no care for 14 hours, including being left in bed soiled and experiencing skin breakdown. This concern was documented on a care concern form indicating she was left 14 hours without staff checking on her, that there was not enough staff, and that she was told she had to go to bed. The Nursing Home Administrator acknowledged that this allegation was not reported externally because it was determined the event did not occur as alleged, and the concern form showed the facility marked the investigation as complete without evidence that the allegation of neglect was reported to the state or that a thorough investigation with supporting documentation was conducted. Additional allegations of neglect involved three other cognitively intact or partially impaired residents who required extensive assistance with transfers, toileting, and hygiene. A CNA reported that on a weekend night there were no CNA staff on the second floor for the entire 12‑hour night shift, and that two nurses were present, one of whom was called in as CNA coverage but continued to function as a nurse passing medications. According to this CNA, two residents were left up in chairs all night and remained in the chairs when day shift arrived, and another resident was found heavily soiled with urine and stool and required a shower after being left in a chair the entire shift. An LPN corroborated that no CNA staff worked that night on the second floor, that a CNA had stayed over late to get most residents to bed but left three residents up in chairs, and that these three residents were still in the same chairs and clothing at the start of the next day shift. Despite these reports, the NHA stated there were no concern forms for these residents in the past 30 days and denied knowledge of three residents remaining up all night on the referenced night shift. The scheduler reported chronic difficulty filling CNA positions, being instructed to add non‑CNA staff such as transportation and medical records staff to the schedule, and having repeatedly completed concern forms related to unmet care needs and staffing issues and provided them to the NHA and DON. The facility’s own abuse prohibition policy requires that all allegations of abuse, neglect, exploitation, or mistreatment be immediately reported, thoroughly investigated, and documented by the Administrator, and reported to appropriate state agencies and others. The documented failure to initiate and complete thorough investigations, to document them adequately, and to report allegations as required constitutes the cited deficiency.
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