Failure to Timely Report and Investigate Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of staff-to-resident abuse to facility administration and/or to the State Survey Agency (SSA) within the required two-hour timeframe for two residents. For the first resident, who had diagnoses including dementia, anxiety, malnutrition, and muscle weakness and was on hospice care, allegations of being hurt by staff resulting in bruising and wounds were reported to the Social Service Worker (SSW) on two occasions. The SSW reported these allegations to the Administrator and Social Service Director (SSD), but there was no evidence that the facility reported or investigated the incidents as required. The Director of Nursing (DON) and SSD acknowledged awareness of the allegations but did not report or document them, with the DON attributing one bruise to a prior fall and the Administrator expressing personal doubts about the validity of the reports, which led to no investigation or reporting. For the second resident, who had heart failure, kidney failure, depression, hypertension, muscle weakness, and was also on hospice care, complaints of rough treatment by staff were made to both the resident's family and facility staff. A Certified Nurse Aide (CNA) reported to the SSD that the resident alleged a staff member had held her hand too hard and caused pain. The SSD documented the allegation in a daily planner but did not report or investigate the incident, and could not recall the reporting CNA. The Administrator later confirmed a lack of awareness and concern that these issues were not reported or investigated as required. These failures were in direct violation of the facility's policy, which mandates immediate reporting of all alleged violations.