Failure to Conduct Timely and Thorough Neglect Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving one resident. The resident had been readmitted with diagnoses including stroke and diabetes, and had an ADL care plan indicating an ADL self-care deficit related to COPD, CHF, pulmonary hypertension, right-sided weakness, and aphasia, with an intervention requiring assist of two for toileting. A significant change MDS with an ARD of 01/16/26 showed the resident had a BIMS score of 10/15, indicating moderately impaired cognition, and was dependent on staff for toileting. A facility investigation dated 01/14/26 documented that a family member reported the resident had not been changed, was calling more often to express concerns, that a CNA spoke to the resident in a rude manner, and that water was not given to the resident. Review of the investigation file showed no evidence that other residents had been interviewed to determine if they had concerns about care provided by CNAs, despite the facility’s abuse, neglect, and exploitation policy requiring identification and interviews of all involved persons, including others who might have knowledge of the allegations. When the DON was asked about resident interviews, the DON later produced interviews but stated they were thought to be in another folder. Follow-up on 02/23/26 revealed that the identified residents had actually been interviewed on that date, not at the time of the original investigation. On 02/25/26, the Administrator acknowledged that resident interviews were not obtained at the time of the investigation, demonstrating that the facility did not conduct an immediate and complete investigation as required by its policy.
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