Failure to Timely Report Allegations of Abuse, Neglect, or Mistreatment
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the appropriate authorities within the required timeframes. Specifically, the facility did not report four separate allegations of abuse, neglect, or mistreatment involving four different residents. These allegations included a nurse allegedly treating a resident poorly and causing emotional distress, a nurse neglecting to change a gastric tube stoma dressing and instructing the resident to do it herself, rough incontinent care resulting in discomfort to an amputated leg, and verbal abuse where a staff member insulted a resident. Record reviews and interviews revealed that these allegations were documented in grievance reports but were not reported to the state agency as required by facility policy and state regulations. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that the grievances were reviewed by the interdisciplinary team, including the previous administrator, but the allegations were not recognized or reported as abuse, neglect, or exploitation (ANE) to the state agency. The current administrator also confirmed that the grievances should have been reported but were not, either due to lack of recognition or assumption that another staff member had reported them. The residents involved had varying degrees of cognitive and physical impairment, including diagnoses such as cerebral vascular accident, seizures, end-stage renal disease, severe obesity, amputation, adjustment disorder with depressed mood, and Parkinson's disease. Their care plans indicated significant needs for assistance with activities of daily living and communication. Despite these vulnerabilities, the facility did not follow established procedures to report the allegations, as confirmed by the absence of corresponding reports in the state’s incident database.