Failure to Timely Report and Investigate Alleged Abuse and Neglect
Penalty
Summary
The facility failed to ensure that allegations of abuse and neglect were reported in a timely manner to the Administrator, as required by policy. A resident with dementia and other medical conditions, who was cognitively intact and required assistance for mobility and toileting, was involved in an incident where she was found yelling and lying beside her bed. Documentation of the incident was incomplete, and there was no immediate follow-up recorded regarding the circumstances of her fall or her condition after the event. A Certified Nursing Assistant (CNA) reported that another CNA placed an incontinence product on the resident and instructed her to urinate in it, rather than assisting her to the bathroom, despite the resident's ability to use the call light and ambulate with assistance. Later, when the resident was found on the floor, a Licensed Practical Nurse (LPN) instructed the CNAs to return the resident to bed without assessing her and placed a hand over the resident's mouth to quiet her when she yelled. The CNA who witnessed these actions did not immediately report the incident to management due to previous negative experiences with reporting at another facility and fear of retribution. The incident was only brought to management's attention several days later, after the CNA informed the scheduler of her concerns and reluctance to continue working at the facility. An investigation was then initiated, and it was substantiated that the LPN did not assess the resident after her fall and that inappropriate actions were taken by both the CNA and LPN. The delay in reporting the incident to the Administrator and the lack of immediate investigation constituted the deficiency.