Failure to Timely Report and Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to timely report an allegation of verbal abuse involving a resident with a history of hemiplegia, hemiparesis, and depression. During a supervised smoking break, the resident alleged that a nurse aide used profanity and a racial slur towards them. The resident reported the incident to the administrator, but the administrator did not immediately recognize or act upon the allegation of verbal abuse. The charge nurse was informed by the resident that the aide had used a racial slur, but did not escalate the report to the RN Supervisor as required, choosing instead to wait for the resident to calm down before seeking further details. The administrator only became fully aware of the specific allegation the following day, at which point the state agency was notified and an investigation was initiated, outside the required reporting timeframe. In a separate incident, another resident with chronic osteomyelitis and a diaphragmatic hernia reported a concern of neglect after waiting several hours for incontinence care. The resident filed a grievance stating that they called for assistance multiple times over a five-hour period before receiving care. The social worker documented the grievance and reported it to nursing and administration, but the Director of Nursing Services (DNS) was unaware of the concern and could not locate documentation of an investigation. The administrator, upon learning of the allegation, spoke with the resident and the assigned aide, but determined that the information did not require reporting to the state agency, despite facility policy requiring immediate reporting of all allegations of mistreatment. Both incidents demonstrate failures in the facility's process for reporting and investigating allegations of abuse and neglect. The facility's own policy requires that all allegations of abuse, neglect, exploitation, or mistreatment be reported to the state agency immediately, but in both cases, the required notifications and investigations were either delayed or not completed according to policy. Documentation was incomplete or missing, and key staff members were not always aware of the allegations or the required procedures for handling them.