Failure to Report and Investigate Allegations of Neglect
Penalty
Summary
The facility failed to prevent and timely report allegations of neglect for two residents. Resident #7, who was dependent on staff for toileting hygiene and needed substantial assistance for personal hygiene, filed a grievance after a CNA yelled at her for needing to be changed. The grievance was not reported to the State Agency, and the Administrator was unaware of it until it was brought to her attention during the survey. The grievance was not investigated as required, and the Social Service Director and Unit Manager were also unaware of the complaint. Resident #1, who had a history of right lower extremity issues and required substantial assistance for hygiene, reported an incident where a CNA allegedly raised her hand as if to hit him. The resident felt threatened and used foul language in response. The incident was reported to the Weekend Supervisor and the DON, but no immediate investigation or skin check was conducted. The DON later determined it was a customer service issue and did not report it as an abuse allegation. Witness statements were not collected from staff present during the incident, and the facility's investigation was incomplete. The facility's policy required immediate reporting of abuse or neglect allegations, segregation of the suspect from residents, and a thorough investigation. However, these procedures were not followed in the cases of residents #1 and #7. The facility failed to document and report the incidents to the State Agency within the required timeframe, and the investigation process was not adequately conducted, leading to a deficiency in handling allegations of neglect.
Plan Of Correction
1) On Resident #7 reported grievance was submitted to AIRS system by NHA. (2) A comprehensive review of all grievances for the months of and was conducted by Regional Vice President of Operations, Executive Director and Social Services Director to ensure adherence to facility policy. No new issues found. (3) 1. Education provided by RVPO to SSD and ED on grievance and reporting process. 2. Education provided to all staff on the grievance and reporting process, postings and placement of grievance forms. 3. All grievances are reviewed by ED, SSD and DON daily; supervisor calls and reviews grievances with ED, SSD, DON or designee on weekends. 4. Grievance policy reviewed by Executive Director in resident council meeting on. 5. A quality review is conducted weekly by ED/DON or SSD on grievances and reportable incidents. (4) A quality review will be completed by the Executive Director/designee of grievances and reportable incidents, to ensure the policy/process is adhered to, 5 times a week for 4 weeks, and then weekly for 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.