Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of potential abuse involving a cognitively intact resident was reported in a timely manner to the State agency (SA). The resident, who had diagnoses including bipolar disorder, anxiety, depression, morbid obesity, chronic pain, and arthritis, required significant assistance with dressing and bed mobility. The resident reported to the social worker that a nursing assistant was 'rough' and 'rude' during dressing care, resulting in shoulder pain and a request for an x-ray. The incident was documented as a grievance, but key sections of the investigation form, including the summary of investigation, corrective actions, and required signatures, were left blank. Multiple staff interviews revealed that the allegation was not reported to the SA because facility leadership did not believe the incident rose to the level of abuse, citing the resident's history of frequent grievances and the absence of physical injury. Despite this, the resident described the care as aggressive and abusive, reporting both physical pain and psychological distress, including nightmares. The nursing assistant involved was placed on a 'do not return' list, but the incident was not escalated as required by facility policy and regulatory guidelines. Facility policy required all reports of abuse, neglect, or exploitation to be reported to local, state, and federal agencies, with immediate notification to the administrator. Staff interviews confirmed an expectation to report such allegations within two hours if serious bodily injury was involved, or within 24 hours otherwise. However, the facility did not follow these protocols, as the allegation was treated as a grievance rather than a reportable abuse incident, and the investigation was not completed or reported in the required timeframe.