Failure to Report and Thoroughly Investigate Alleged Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was properly reported to the state survey agency (SSA) and that the investigation documentation was thorough. The facility's policy required immediate investigation and reporting of any suspicion or report of abuse, neglect, or exploitation, including interviewing all involved persons and providing complete documentation. In this case, a resident with severe cognitive impairment, aphasia, and hemiplegia reported to a therapy staff member that a geriatric nursing assistant (GNA) hurt their arm during care. The Director of Social Work (DSW) interviewed the resident, who described an incident involving impact with a bedside table but was unclear if it was intentional or accidental. The DSW interviewed the assigned GNA and several other residents, finding no additional concerns, and submitted the information to the Administrator. However, the facility did not report the allegation to the SSA, as the DSW believed the incident was accidental. The Administrator confirmed that the decision not to report was based on the belief that not every negative statement constituted abuse. The facility maintained a "soft file" with statements from the DSW, the GNA, and documentation of interviews with other residents, but did not include statements from the therapy staff member who initially received the allegation or other potentially knowledgeable staff. Further interviews revealed that the Director of Rehabilitation (DOR), who first heard the allegation, was not asked for a statement until much later, and her account indicated the resident had repeatedly stated the staff was rough and hit their arm. The Director of Nursing (DON) stated that all abuse allegations should be reported and investigated. The Administrator later acknowledged that the allegation should have been reported and that the investigation did not include interviews with all relevant staff members. The documentation did not reflect a complete or thorough investigation as required by facility policy.