Failure to Identify and Report Abuse Allegation; Lapse in Staff Training
Penalty
Summary
The facility failed to identify and respond appropriately to a grievance that constituted an allegation of abuse or neglect for one resident. Specifically, a resident with diagnoses including orthostatic hypotension, cellulitis, dementia, and malnutrition reported being left alone in a transport wheelchair for six hours, resulting in significant discomfort. The grievance, documented by the facility, indicated the resident was left unattended from 1:00 PM to 7:00 PM. Despite this report, the incident was not escalated as an allegation of abuse or neglect, nor was it reported to the state agency or investigated as required by facility policy and regulatory standards. Interviews with staff revealed uncertainty about the process for handling such grievances, with some staff indicating they would notify a nurse or administrator, but no clear action was taken to treat the report as a potential abuse or neglect case. Additionally, the facility failed to ensure that all staff received annual abuse and neglect training as required. Review of training records showed that one staff member had not completed the required training within the past 12 months. Staff interviews confirmed that annual training was expected, but there was a lack of clarity regarding the last training dates. These failures in both grievance handling and staff training placed residents at risk for abuse, neglect, and associated harm.