Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse and neglect to the State Agency as required, involving two residents. In the first case, a resident with bipolar disorder, morbid obesity, and chronic congestive heart failure, who was moderately cognitively impaired and dependent on staff for mobility and care, reported that a nurse aide was often in a bad mood, made dismissive comments such as 'this is just a job,' and made remarks about the resident's weight. The grievance form documenting these concerns was not signed by staff, and the Director of Nursing Services (DNS) did not report the allegation to the State Agency at the time, believing the resident wished to remain anonymous. The DNS also did not fully investigate the weight-related comment and only reassigned the nurse aide from the resident's care. Interviews confirmed that the comments were inappropriate and that the situation had potential for verbal abuse, but the required reporting did not occur until much later, after surveyor inquiry. In the second case, a resident with severe cognitive impairment, muscle weakness, and incontinence was found by their responsible party to be in pajamas late in the morning with a very soiled and odorous pull-up. A grievance was filed by the responsible party, and the social worker noted that staff would be re-educated on toileting rounds. However, there was no documentation of an investigation or staff education, and the DNS was unaware of the grievance until the survey. The DNS confirmed that if she had been aware, she would have reported the allegation to the State Agency, but this did not occur until prompted by the surveyor. The staff involved in the original grievance were no longer employed at the facility, and no further information was available from them. Facility policies required immediate reporting and investigation of any potential allegations of abuse, neglect, or exploitation. Despite these policies, the facility did not follow the required protocols for reporting and investigating the allegations in both cases. The lack of timely reporting and incomplete documentation contributed to the deficiency identified by surveyors.