Failure to Timely Submit Written Abuse Investigation Findings to State Agency
Penalty
Summary
The facility failed to provide the State Survey Agency (SSA) with a written report of the findings from its internal investigation of an alleged abuse incident within five working days, as required by policy. The incident involved a resident with severe cognitive impairment and significant care needs, including dependence for eating, personal hygiene, and dressing, who was admitted with diagnoses such as hypertension, tracheostomy, and gastrostomy. The alleged abuse occurred when a Certified Nurse Assistant was reported to have yelled at the resident while providing care. The Infection Preventionist was assigned to conduct interviews and prepare the final investigation report, but as of the time of the survey, the report had not been submitted to the SSA within the required timeframe. The facility's own policy mandates that a thorough investigation be conducted and a final written report be submitted to the Department of Health Services within five business days. The Administrator confirmed that while the initial report of suspected abuse was submitted, the final written investigation findings were not provided within the mandated period.