Failure to Thoroughly Investigate Allegation of Neglect and Call Light Malfunction
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving Resident 1, one of three sample residents. Resident 1, who had a diagnosis of recurrent acute diverticulitis and reported being very sick and in pain, stated that sometime in January she repeatedly used her call light and called out in pain for approximately four hours without staff responding. She reported that someone closed her room door and that she later discovered her call bell was not connected, although she had not initially realized it was unplugged. She stated that, after no one responded, she called the hospital emergency room herself, and when the ambulance arrived and transported her out of the room, she saw an LVN at the desk and told the LVN she had been calling for hours for help. A hospital discharge summary dated 1/15/2026 documented her diagnosis of recurrent acute diverticulitis. During interviews, LVN 1 characterized the resident as having a history of false accusations and stated that the resident never turned on the call light or called for help, and that staff found her asleep during rounds. The Unit Supervisor reported that he conducted an investigation based on the resident’s complaint that she had been in pain for four hours, had used her call light, and had been unaware that her call light was unplugged from the wall. However, the Unit Supervisor did not document any part of his investigation, including interviews with nurses or the resident, and could not provide specific dates, times, or content of those interviews. He also did not interview other residents, roommates, family members, or responsible parties as required by facility policy. When the resident’s call light was later tested, the cord-out feature did not trigger an alarm at the nursing station, and additional rooms were found with non-functioning cord-out features. The Maintenance Director stated he was unaware the call light system had a cord-out feature and did not include it in his routine maintenance checks. The facility’s Abuse-Reporting & Investigations policy required interviewing individuals who may have information relevant to the allegation, such as the resident, witnesses, other residents, roommates, family, and visitors, which was not done in this case.
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