Failure to Timely Investigate and Document Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate and document allegations of abuse in a timely manner for multiple residents. In several instances, residents reported that staff were rough, mean, or made inappropriate comments during care. For example, two residents reported that a nurse was rough and had a poor attitude, but there was no evidence that the facility conducted a timely or thorough investigation after these concerns were reported to a unit manager and later to the Director of Nursing (DON). The only documentation provided was a single statement form, with no further evidence of interviews, assessments, or protective measures taken while the investigation was pending. Another resident reported that a Geriatric Nursing Aide (GNA) made hurtful comments about the resident's weight and was rude during care. Although the incident was documented as a concern, there was no evidence that the facility conducted a thorough investigation, assessed the resident, or interviewed staff and residents in a timely manner. The Nursing Home Administrator (NHA) acknowledged that the incident was not treated as abuse and that the GNA was only verbally instructed not to return to the resident's room. Additional incidents included a resident calling 911 to report being aggressively grabbed by a nurse, with a significant delay in conducting required assessments after the NHA was notified. In another case, a family member reported aggressive care by a GNA, but the resident's assessment was not completed until the following day. The DON confirmed that immediate assessments and investigations were not performed as required in these cases.