Failure to Investigate and Report Alleged Resident Mistreatment
Penalty
Summary
The facility failed to investigate and report an alleged incident of mistreatment involving a resident with moderate cognitive impairment and significant physical dependencies. The resident, who had a history of cerebrovascular accident, hemiplegia, and diabetes, reported that a CNA left her on a bed pan for five hours without access to a call light and later acted disrespectfully and possibly under the influence while providing care. The resident did not initially report the incident to management due to fear but did inform a nurse, who later became the DON, and was told that steps would be taken. A review of the resident's electronic health record did not show any documentation of the incident or any assessments of the resident's cognitive or physical condition following the alleged event. Additionally, there was no record of the incident being reported to the State Agency as required. The DON, who had recently assumed her position, confirmed that the previous administration was aware of the incident, as it was discussed in management meetings, but no investigation or report to the State Agency was completed. Facility policy requires immediate reporting and investigation of alleged abuse, neglect, or mistreatment, including notification of designated agencies within specified timeframes. Despite these policies, the facility did not follow through with the required investigation or reporting procedures in this case, and the staff member involved was later terminated for unrelated reasons. The lack of timely investigation and reporting constituted a failure to comply with regulatory requirements for protecting residents from abuse and ensuring proper oversight.