Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse and neglect to the required agencies in a timely manner for two residents. For one resident with muscle weakness, Charcot's joint, and a chronic non-pressure ulcer, a fall occurred when a CNA used a mechanical sit-to-stand lift without following the care plan, which required two staff members for transfers. The incident investigation determined that the CNA neglected to follow both the resident's care plan and facility policy. Despite this, there was no documentation that the incident was reported to the local Area Agency on Aging or the state survey agency, as required by facility policy. In a separate incident, another resident filed a grievance alleging that a staff member had kicked him during care. The facility's investigation found the abuse allegation to be unsubstantiated, but again, there was no evidence that the allegation was reported to the required agencies. Interviews with the Nursing Home Administrator confirmed that both incidents should have been reported according to policy, but were not.