Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of verbal and physical abuse to the State Agency as required. A resident with a history of flaccid hemiplegia, dysphasia, hypertension, hyperlipidemia, epilepsy, and arthritis, who is cognitively intact and dependent on staff for mobility and hygiene, reported that a CNA was rough during a shower, causing pain and discomfort to his private area with the transfer sling. The resident stated that his complaints were ignored during the incident, and after being put to bed soaking wet, he informed his mother, who subsequently reported the incident to the facility's Social Service Director. Despite the report from the resident's mother, the Social Service Director did not document the concern in the grievance book or interview the resident, instead passing the information to the Administrator. The Administrator acknowledged receiving the complaint and issued a disciplinary write-up to the CNA but did not interview the resident, the CNA's coworker, or conduct a formal investigation into the allegation. The Administrator also confirmed that the incident was not reported to the State Agency as required by facility policy and federal regulations. The facility's own Abuse Prevention Program policy mandates immediate reporting of all alleged violations involving abuse, neglect, or mistreatment to the administrator and appropriate authorities, as well as a thorough investigation and a written report within five working days. In this case, the facility did not follow these procedures, as the allegation was neither reported to the State Agency nor properly investigated, and no documentation of the incident was made in the facility's grievance records.