Failure to Promptly Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to promptly investigate and report allegations of abuse involving a resident. On 12/29/24, a resident reported to an LPN, who was not assigned to her care that day, that a CNA had stayed in her room despite being asked to leave, used inappropriate language and gestures, and used a phone to take pictures and record her. Another staff member, a CNA, was also informed by the resident that the CNA in question had been disrespectful during personal care. The assigned RN, after being notified, went to the resident with two other staff members to discuss concerns, but the resident stated she had no concerns at that time. The CNA who received the complaint wrote a statement about the incident. The RN and LPN contacted the assistant director of nursing (ADON) to report the incident. The RN reported that the resident was having behaviors toward staff, while the LPN mentioned the resident's concerns about a CNA but did not provide specific details. The ADON instructed them to document the interaction and to ensure the staff member in question did not provide care to the resident. The following day, the director of nursing (DON) reviewed the progress notes and asked the social services director to speak with the resident, but no further information was obtained. Despite these actions, the incident was not reported to the administrator, law enforcement, or the state health department, and no formal investigation was initiated at that time. It was not until a discharge follow-up call several weeks later that the resident repeated the allegations, prompting the administrator to initiate an investigation and report the incident to the appropriate authorities. The subsequent investigation validated the allegation of verbal abuse, and the CNA involved was terminated. The delay in investigation and reporting constituted a failure to ensure that allegations of abuse were promptly addressed as required.