Failure to Report and Investigate Resident's Objection to Staff Handling
Penalty
Summary
The facility failed to report an incident involving a resident with multiple medical conditions, including hypertension, pain, muscle weakness, and major depressive disorder, who primarily used a wheelchair for mobility. On the date in question, multiple staff members witnessed a maintenance staff member pushing the resident in her wheelchair despite her repeated requests to stop and her desire to go to the activity room. Staff members, including a CNA and dietary staff, observed the resident expressing her wish for the maintenance staff to stop, and one staff member reported that the resident did not appear jovial about the interaction. Grievances were filed by staff who witnessed the event, but they were not interviewed about what they saw. The incident was reported up the chain to a licensed nurse and then to administrative staff, who acknowledged being informed that the resident was taken by the maintenance staff and that her whereabouts were temporarily unknown. Although the administrator later interviewed the resident, who downplayed the incident, no formal investigation was conducted, and the staff who filed grievances were not individually interviewed. The facility did not report the incident to the State Agency as required by its own abuse, neglect, and exploitation policy, nor did it complete a written investigation into the staff grievances related to the event.