Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse and/or neglect to the State Agency for two residents who were reviewed for grievances. According to facility policy, all alleged violations of abuse, neglect, exploitation, or mistreatment must be reported within specified timeframes depending on the severity. However, in the case of one resident with bipolar disorder and epilepsy, who was assessed as having moderately impaired cognition and significant behavioral issues, an incident occurred where the resident reported feeling intentionally assaulted by another resident's representative. The nursing assistant who received this report did not notify the State Agency, and the incident was not logged as an allegation of assault, but rather as a skin issue. Facility administration was unaware of the allegation until after the fact, and the administrator acknowledged missing the relevant information in the incident statement. In another case, a resident with a right hip fracture and bipolar disorder, also with moderately impaired cognition and requiring substantial assistance, reported to a staff member that a nursing assistant was rude, unhelpful, and made the resident feel helpless and depressed. The grievance, written by the assistant rehab director, described the resident crying and expressing emotional distress due to the staff member's behavior. This grievance was not entered into the facility's grievance log, nor was it reported as an incident. The nursing assistant involved did not report the resident's emotional state or any change in condition, and only apologized after learning of the complaint from another staff member. Interviews with facility leadership revealed that the administrator and assistant director of nursing were unaware of the grievances and did not recognize them as potential abuse or neglect, resulting in a failure to initiate investigations or report the allegations as required. The facility's actions and omissions in both cases led to a lack of timely reporting and investigation of potential abuse or neglect, as required by policy and regulation.