Failure to Immediately Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was reported immediately to the state agency and the facility administrator, as required. The resident, who had significant cognitive and physical impairments including dementia, hypovolemia, cirrhosis, and dependence on staff for daily care, reported to multiple staff members that she experienced rough handling and yelling from staff during care. She described being treated roughly by two nursing assistants, which caused her pain for several days, and stated that one staff member consistently yelled at her. The resident communicated these concerns to various staff members, but was unable to provide specific dates due to her cognitive and physical limitations. Multiple staff interviews revealed that several staff members were aware of the resident's complaints of rough care and verbal abuse. Some staff reported these concerns to their supervisors or nurse managers, while others did not report them, either because they did not witness the incidents firsthand or because they believed the resident frequently complained. One staff member reported the allegations to the state agency independently, but not on behalf of the facility, citing a lack of trust in the facility's willingness to investigate or act on such reports. The facility's grievance log did not contain any entries related to the resident's complaints during the relevant period. The nurse manager and administrator both indicated that they had not received specific reports of abuse or rough care regarding the resident, and the nurse manager admitted to not investigating rumors of possible abuse. The facility's policy required immediate reporting of suspected abuse, neglect, or mistreatment to both the facility and the state agency, but this protocol was not followed in this case. As a result, the required immediate reporting and investigation of the abuse allegation did not occur as mandated.