Failure to Report Abuse Investigation Results to State Agency
Penalty
Summary
The facility failed to report the results of an abuse allegation involving a resident with dementia, encephalopathy, hypertension, diabetes mellitus, and end stage renal disease. The resident, who had impaired cognition and required supervision for mobility and transfers, exhibited increased agitation and aggressive behaviors, including hitting and kicking staff. During a breakfast incident, a CNA restrained the resident's arms and, when the resident attempted to bite her, struck the resident in the face with an open hand. Multiple staff and another resident witnessed the event, but the CNA and a witness did not report the incident to management. The Director of Nursing was notified of the incident by an LPN and initiated an internal investigation, confirming that the CNA had struck the resident. However, both the DON and the Administrator concluded that the CNA did not intend harm and, as a result, did not report the incident or the investigation results to the State Survey Agency as required by facility policy and state law. The facility's policy mandates reporting the results of all investigations to the appropriate authorities within five working days, but this was not done in this case.