Failure to Identify and Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to identify and report allegations of abuse and/or neglect for three of five sampled residents. For one resident with severe cognitive impairment, a family member submitted a grievance after witnessing the resident's roommate engage in inappropriate physical contact, including kissing the resident on the lips. The facility's social worker investigated by interviewing the resident and others, but did not report the incident to the state, as required by policy. Staff interviews confirmed that all were aware of their mandated reporter responsibilities, and both the LPN/Staff Development Coordinator and the Administrator acknowledged that the incident should have been reported as an allegation of abuse. Another resident, who was alert and oriented, reported waiting 30 minutes for their call light to be answered when needing to use the bathroom, causing distress. The facility documented the incident as a grievance and determined that abuse and neglect were ruled out, as the nursing assistant had gone on break without informing the nurse. The incident was not initially reported to the state, and the LPN/SDC who investigated was unsure why it was handled as a grievance. The Administrator later submitted an incident report to the state after being questioned. A third resident, with moderate cognitive impairment and a history of brain injury, complained during a resident council meeting about waiting over 30 minutes for assistance with toileting and being scolded by an aide after self-transferring to the toilet. There was no documentation of this allegation in the resident's health record, nor was it reported to the state. Staff interviews confirmed that such incidents should be reported as potential abuse or neglect, and facility leadership agreed that the complaint should have been escalated and reported.