Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to follow its abuse policy and procedures for two residents when an allegation of employee-to-resident abuse was not reported to the state licensing/certification office, police, or ombudsman, and the incident was not investigated in a timely manner. Resident 2, who had intact cognition and the capacity to make decisions, filed a grievance on behalf of Resident 3, who had severe cognitive impairment and was dependent on staff for most activities of daily living. The grievance described an incident in which a CNA allegedly proceeded forcefully with care despite the resident's refusal, resulting in the resident yelling and screaming in resistance. Interviews and record reviews revealed that the Director of Nursing acknowledged the grievance contained an allegation of abuse and should have been reported, but it was not, as there was no physical problem observed. The Administrator stated he was aware of the incident but was not informed of the specific details indicating forceful behavior, which would have prompted reporting. The facility's policy required immediate reporting of all alleged violations of abuse to appropriate authorities, but this procedure was not followed in this case.