Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to implement its abuse prevention policies when concerns about the treatment of a resident were not reported within the required two-hour timeframe, and a thorough investigation was not completed. A staff LPN observed two CNAs neglecting call lights, delaying rounds, and interacting with a resident in a condescending and dismissive manner during the night shift. The resident, who had a BIMS score indicating no cognitive impairment and required assistance for toileting, was denied timely help and subjected to inappropriate communication by staff. The LPN reported these concerns to a day shift RN but was unsure if further reporting occurred, and only provided a written statement to the DON after a delay of more than two days. The facility's investigative file revealed significant gaps in the investigation process. Although the facility's policy required immediate reporting of abuse allegations to the administrator and a thorough investigation, the initial report to the state agency was not made until several days after the incident. The investigation did not include follow-up interviews with the resident after her initial statement, nor did it include interviews with her roommate regarding the incident or with all staff who had contact with the resident during the relevant period. The social worker who interviewed the resident did not pursue further questions or follow-up, and the DON was unaware of key statements made by the resident. Documentation of the investigation was incomplete, lacking evidence of follow-up on the resident's psychosocial status and missing interviews with relevant staff and witnesses. The facility's own policies outlined the need for comprehensive documentation and interviews, but these steps were not fully carried out. The resident involved reported being left on the side of her bed for two hours in pain and feeling abused, but there was no documented follow-up to assess her well-being after the incident.