Failure to Timely Report Investigation Results of Abuse and Neglect
Penalty
Summary
The facility failed to report the results of all investigations of suspected abuse, neglect, or theft to the administrator or designated representative and to the State Survey Agency within five working days, as required by regulation. This deficiency was identified in three out of seven residents reviewed for abuse and neglect. In one instance, a resident with a history of dementia and major depressive disorder struck another resident in the face while attempting to take a personal item. The facility's investigative summary was completed and signed by the Assistant Director of Nursing Services, but there was no documented evidence that the results of the investigation were reported to the State Survey Agency within the required timeframe. Another incident involved a resident with right hemiplegia, Parkinson's disease, and severe cognitive impairment, who was dependent on a two-person mechanical lift for transfers. Two CNAs transferred the resident using a stand pivot instead of the required mechanical lift, resulting in the resident being lowered to the floor and later diagnosed with a femur fracture. Although the initial incident report was submitted to the State Survey Agency, there was no documentation that the results of the investigation were reported within five working days, nor evidence that appropriate corrective action was communicated if the violation was verified. Interviews with facility staff, including the DON and administrator, revealed gaps in knowledge and documentation regarding the investigation and reporting process. The DON and Assistant DON were either new to their positions or not involved in the investigations, and the investigative files were missing or not properly filed by previous administrators. This lack of documentation and timely reporting constituted a failure to comply with state regulations for reporting the results of abuse and neglect investigations.