Failure to Report and Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to effectively implement its abuse prevention policy regarding the timely reporting and thorough investigation of an allegation of abuse involving a resident with multiple cognitive and behavioral diagnoses. The resident, who had a history of dementia, agitation, and non-compliance with care, was involved in an incident with a CNA, during which the CNA verbally threatened the resident after an altercation. Witness statements and interviews confirmed that the CNA used threatening language toward the resident, and that the incident was witnessed by other staff members. Despite the facility's policy requiring immediate reporting of abuse allegations to the Administrator and the state health department, as well as prompt removal of the accused staff member and thorough documentation, the incident was not documented in the resident's medical record, and no Self-Reported Incident (SRI) was submitted to the state. The personnel file for the CNA showed termination for the incident, but there was no evidence that the required notifications or documentation were completed. The Director of Nursing acknowledged the incident but stated that conflicting accounts prevented a determination of what occurred, and confirmed that no SRI was submitted and the nurse aide registry was not notified. The facility did not provide additional documentation or information regarding the incident, and interviews with staff revealed inconsistencies in their accounts. The facility's failure to follow its own abuse policy resulted in a lack of timely reporting, incomplete investigation, and insufficient documentation of the incident involving the resident and the CNA.