Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to implement its policies and procedures for reporting allegations of abuse and neglect for five of twelve residents. According to the facility's own policy and state law, all suspected abuse or neglect must be reported to the appropriate authorities, including the Department of Health and the Area Agency on Aging. However, review of clinical records, concern forms, and interviews revealed that multiple allegations made by residents were not reported as required. One resident, with a history of diabetes, coronary artery disease, and fibromyalgia, reported verbal abuse by the Medical Director and stated she had informed multiple staff members. Despite this, there was no grievance entered on her behalf, and the allegation was not reported to the state agency. Other residents, all with BIMS scores indicating they were cognitively intact, reported issues such as missed showers, lack of assistance from staff, and rough handling by a nurse aide. These concerns were documented in facility records but were not reported to the appropriate authorities as allegations of neglect or abuse. Interviews with facility leadership, including the Nursing Home Administrator and Director of Nursing, confirmed that the facility was aware of these allegations but failed to follow through with mandated reporting procedures. The review of submitted reports to the state agency showed that none of these incidents were included, indicating a systemic failure to comply with both facility policy and state regulations regarding the timely reporting of suspected abuse and neglect.