Failure to Maintain Documentation of Abuse Allegations
Penalty
Summary
The facility failed to maintain required documentation related to allegations of abuse for two of six facility reports reviewed during the annual recertification survey. In one instance, the surveyor requested information regarding an abuse allegation reported to the State Agency, but the Director of Nursing (DON) stated that no records related to the report were available. Although the State Agency's records indicated that the investigation was completed and reporting occurred within the required timeframe, the facility did not retain documentation of the incident investigation or the reporting process, and exact incident times were not documented. In another case, a resident reported that a geriatric nursing assistant (GNA) tried to fight and refused to assist with personal care. The incident was documented as a change in condition, and the GNA was suspended pending investigation. The resident was followed by psychiatric services, and the facility determined there was insufficient evidence to support the abuse allegation. However, when the surveyor requested the facility report and Facility Reported Incident (FRI) documentation, the DON was unable to provide either electronic or hard copy records related to the incident.