Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to ensure that allegations of abuse involving a resident were reported immediately to the appropriate authorities, including the state agency, as required by regulation. Two separate incidents involving a resident and two different CNAs were not reported within the mandated timeframe. In one incident, a resident with intact cognition and multiple medical diagnoses, including Parkinson's disease and dementia, reported that a CNA had been rough with them. The incident was relayed to a registered nurse, who reassigned the CNA to another hallway but did not complete a body audit or resident interview, nor was the incident reported to the state agency until fourteen days later. In a separate incident, another CNA was also alleged to have been rough with the same resident. The CNA supervisor reassigned the CNA to another hall but did not document the incident or report it to supervisory staff or authorities. The administrator's investigation into this incident consisted of a brief two-page report, which included a statement from the CNA supervisor and a warning record for the CNA, but no body audit or nurse assessment was completed for the resident. The administrator confirmed that this allegation was not reported to the mandatory authorities or the state agency. Despite the facility's abuse and neglect policy and documented in-service training for staff, including the administrator and ADON, on the identification and reporting of abuse, the required procedures were not followed. The failure to report these allegations in a timely manner and to conduct appropriate assessments resulted in non-compliance with federal requirements and was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The deficiency was cited at the Immediate Jeopardy level.
Removal Plan
- In-service training for all staff on reporting abuse and neglect to the Administrator, the DON, and Office of Long-Term Care, ensuring all incidents are reported properly and to ensure resident safety.
- Interviewed residents regarding abuse and performed body audits on residents unable to verbalize abuse.
- Appointed the Director of Nursing (DON) to monitor, investigate, and report allegations of abuse.
- Implemented a monitoring tool for documenting and reporting of allegations.
- Appointed the DON as the Abuse and Neglect Coordinator with all corrections completed.
- Conducted staff interviews from all shifts to verify training had been completed.
- Ensured that staff not yet trained are not allowed to return to work until they have been trained.