Failure to Timely Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to respond appropriately to allegations of abuse involving three residents. In the first case, a resident with cerebral palsy and anxiety reported that another resident with Alzheimer's disease and agitation had grabbed their neck and pushed their wheelchair, leading to a retaliatory act where the first resident ran over the other's feet. This incident was not documented in the care plans or nursing notes, and the Director of Nursing Services (DNS) was unaware of the event until informed by a surveyor. The incident was not reported to the State Agency immediately, and the investigation summary was delayed. Additionally, the involved residents' representatives were not notified, and staff members who were aware of the incident did not escalate it to administration as required by policy. In another instance, a resident with dementia and depression alleged that a nurse aide had pushed them into the bathroom. The resident was unable to identify the aide, but consistently described the aide as mean and bossy. The allegation was not reported to the DNS or administration by the staff who were aware of the resident's concerns. The resident's representative also failed to report the concern, believing it may have been a misunderstanding. When the DNS was finally informed by a surveyor, the incident had not been documented in the care plan or nursing notes, and the staff member involved was not identified or removed from duty as required by facility policy. Across both cases, the facility did not follow its abuse policy, which requires immediate initiation of a thorough investigation, removal of the involved staff member, and timely reporting to the State Agency. Documentation was lacking, and there were delays in both internal and external reporting. Statements from involved staff were incomplete or missing, and the required investigation steps were not followed promptly or thoroughly.