Failure to Investigate and Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated and reported as required. For four out of ten residents reviewed, there was no evidence that allegations of abuse, neglect, or mistreatment were properly investigated or that further potential harm was prevented during the investigation process. The facility also did not report the results of these investigations to the state agency, as required by policy and regulation. One resident with severe cognitive impairment and a history of stroke and seizures was alleged by her representative to have been treated poorly by a nurse, resulting in the resident crying, which was noted as rare for her. Another resident, who was cognitively intact and dependent on a gastrostomy tube for nutrition, alleged that a nurse neglected to change her tube dressing and instructed her to do it herself, contrary to her care plan requiring staff assistance. In both cases, grievance reports were documented, but the DON stated she did not recall the reports and had not reported the investigation results to the state agency. A third resident, with end-stage renal disease, severe obesity, and an above-knee amputation, alleged rough incontinent care by a staff member, resulting in soreness to her amputated leg. The ADON recalled discussing the allegation but did not report the results to the state agency. A fourth resident, with severe cognitive impairment and a history of depression and Parkinson's disease, alleged verbal abuse by a CNA. The ADON and administrator discussed the allegation but did not recognize it as reportable. A review of the state incident database confirmed that none of these allegations were reported as required. The facility's policy mandates immediate reporting of such allegations, but this was not followed.