Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of neglect to the State Agency as required by federal and state regulations. According to the facility's own policy, any suspicion of abuse, neglect, exploitation, or misappropriation of resident property must be reported immediately to the administrator and to other officials, including the State Agency. In this case, a resident with diagnoses including high blood pressure, diabetes, muscle weakness, and cognitive communication deficit reported to a registered nurse that a certified nursing aide had pushed her wheelchair hard and on purpose after telling her to use the wheelchair to go to the bathroom instead of walking. The resident requested that the aide not be assigned to her again and wanted the incident addressed in writing. The Director of Nursing and Nursing Home Administrator were made aware of the situation, and it was decided that two aides would be required to provide care to the resident going forward. Despite the facility's policy and the seriousness of the allegation, documentation provided to the State Agency did not include this incident. During an interview, the Director of Nursing confirmed that the facility failed to report the allegation of abuse to the State Agency for this resident. This omission constitutes a failure to comply with both federal and state requirements for reporting alleged violations involving abuse or neglect.
Plan Of Correction
F 0609 R325 was interviewed by management immediately after discovering this nurse's note. Resident recalled the comment and stated she didn't like the aide taking her to the bathroom in a wheelchair as she preferred the walker. A grievance form was completed for not following resident preference and resolved to the resident's satisfaction. Allegation of abuse was reported upon receipt of survey results. A review of the last 30 days of grievances was conducted to ensure no other grievance was reported as an allegation of abuse that should have been, with no negative findings. DON and unit managers will be educated by the NHA to review the 24-hour progress note report daily for any notes triggering an allegation of abuse and report accordingly. NHA or designee will audit 24-hour progress notes for the same weekly for 4 weeks, then monthly for 2 months. Results will be reviewed at QAPI and revised as needed. F 0609