F0610

D

Failure to Investigate and Document Resident Neglect Allegations

Denton, Maryland Survey Completed on 03-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to thoroughly investigate and respond to allegations of neglect made by a resident. Medical record review showed that a hospital consult report, uploaded into the resident’s chart on 12/13/2025, documented that the resident went to the Emergency Department and reported being constantly neglected by the 11 p.m. to 7 a.m. shift, frequently sitting in urine, and having call bells purposely ignored, leading the resident to call 911 for help. The Administrator stated he was not aware of this complaint or of any investigation related to it, despite confirming that such reports of neglect should be brought to his attention and investigated, and that the Emergency Department note had been uploaded by facility staff. The DON reported that the admitting nurse should have reviewed the discharge paperwork when the resident returned from the hospital and should have noted the resident’s complaint of neglect.

A second deficiency component was identified through review of Facility Reported Incident #2690114, in which the same resident had reported an allegation of neglect and being left in soiled conditions for an extended period. The DON could only provide the initial incident report submitted to the Office of Health Care Quality and was unable to locate any additional documentation or an investigation file for this incident. She stated that a file containing interviews and evidence is normally maintained for each Facility Reported Incident and confirmed that such a folder should exist for this resident but could not be found. The Administrator similarly confirmed that investigation notes and interviews are kept in a folder in a file cabinet and that the previous DON had handled the investigation for this incident, but the investigation file could not be located.