Failure to Identify and Report Allegations of Abuse
Penalty
Summary
The facility failed to identify and report allegations of abuse for two residents. For one resident with a history of fracture, diabetes, insomnia, and chronic pain, a verbal altercation with a roommate was documented in the incident log. Although the incident report indicated it was reported to the state hotline, there was no documentation to confirm this, and the Director of Nursing Services could not provide evidence that the report was made to the state agency. In another case, a grievance was filed by a resident who reported that a staff member acted inappropriately during care, including grinning, singing, and winking while the resident was undressed. The facility's investigation was limited to providing customer service training to the staff member and did not include interviews with other residents or a formal investigation to rule out abuse. The Director of Nursing Services acknowledged that no investigation was conducted for this allegation, and the Administrator was not present during the time of the grievance.