Failure to Report and Investigate Abuse Allegation
Penalty
Summary
The facility failed to implement its Abuse and Neglect policy regarding the reporting and investigation of an abuse allegation involving a resident with Parkinson's Disease, chronic pain, and anxiety disorder. The resident, who was non-ambulatory and required assistance with transfers and activities of daily living, developed swelling and pain in the right hand, which was later found to have a questionable fracture. Initial assessments by nursing staff and the primary care physician attributed the symptoms to a possible gout flare, and subsequent lab work and imaging were ordered. However, no incident or accident report was completed regarding the injury at the time. During interviews, it was revealed that the resident had reported to nursing staff that a CNA had been rough during care, and the resident associated the finger injury with this incident. The nurse who received the complaint instructed the CNA not to return to the resident's room and reported the allegation to the ADON. However, neither the nurse nor the ADON reported the allegation to the Administrator or DON as required by facility policy, nor did they document the assessment or initiate an investigation at that time. The ADON and RN both acknowledged being aware of the resident's complaint but did not take further action beyond informal reassignment of staff. The Administrator and DON only became aware of the abuse allegation during the survey process, several days after the initial complaint and injury. At that point, the facility began the process of investigating and reporting the allegation to the appropriate authorities. The delay in reporting and investigating the abuse allegation, as well as the lack of documentation and failure to follow established policy, constituted the deficiency identified by surveyors.