Failure to Investigate Allegations of Abuse and Neglect Involving Two Residents
Penalty
Summary
The facility failed to thoroughly investigate allegations of potential abuse and neglect involving two residents. For one resident with COPD with acute exacerbation and respiratory failure, a former staff member reported that on a specific date an LPN assigned to the resident refused to administer ordered pain medication despite reports from other staff that the resident was screaming, short of breath, and very anxious. The former staff member stated she was not informed of the incident at the time and therefore did not investigate it. The Administrator later acknowledged that no investigation was completed, could not provide any documentation showing an investigation or how abuse/neglect was ruled out, and stated she felt the incident was handled by the facility. The LPN involved stated she did not remember if she gave the medication and would need to check the medical record, but did not provide further information or documentation. Another LPN/Unit Manager confirmed awareness of the allegation that the LPN refused to give the resident morphine despite being told the resident was distressed, and also acknowledged that no investigation was completed. For a second resident with a hip fracture and dementia, a former staff member reported being notified that an LPN forced the resident to stay up in a wheelchair for most of the night at the nurse’s station and continuously gave the resident coffee because the LPN did not want to deal with the resident falling and any potential incident reports. The former staff member reported that she notified the Administrator of this incident. The DNS stated there should have been an investigation for this allegation and clarified that while residents could be monitored at the nurse’s station, this should not occur for the entire night or for staff convenience. The Administrator again acknowledged that no investigation was completed for this incident, could not provide any documentation of an investigation, and stated she felt the incident was handled by the facility.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.