Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident who had a history of cerebral infarction and required assistance with personal care. The resident's responsible party informed the facility that a female CNA was rough and rude during care, and the resident described being handled roughly and spoken to inappropriately by the CNA. Despite this, the Social Service Director (SSD) did not treat the complaint as an allegation of abuse, citing the resident's confusion and inability to recall details during an interview. The incident was only filed as a grievance, and no further investigation or follow-up, such as interviewing the roommate or monitoring for psychosocial changes, was conducted. The SSD reported the incident to the Abuse Coordinator, who determined the allegation was unfounded due to the resident's confusion. The Director of Staff Development and the Director of Nursing both acknowledged that the allegation should have been treated as suspected abuse, reported, and investigated according to policy, which requires immediate reporting to state and local agencies. The facility's policy defines 'immediately' as within two hours for allegations involving abuse or serious bodily injury, but this protocol was not followed in this case.