Failure to Investigate and Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate and report allegations of abuse, neglect, exploitation, or mistreatment for multiple residents, as required by federal regulations. In several cases, there was no evidence that a comprehensive investigation was conducted or that the results were reported to the state survey agency within five working days. For example, one resident reported to a family member that a CNA was rough during repositioning, causing her contracted legs to hit the wall. Although the incident was reported to the former Social Worker and Administrator, there was no documentation of an investigation or submission of findings to the state. Another resident with severe cognitive impairment and multiple medical conditions, including a recent surgery and infection, experienced missed doses of IV antibiotics due to a pulled PICC line and a failure to enter medication orders promptly. Nursing notes documented behavioral issues and repeated attempts to remove medical devices, but the facility did not provide investigation reports for these incidents. The ADON confirmed that the previous Administrator handled self-reports and that no investigation documentation was available for review. Additional incidents included a resident-to-resident altercation resulting in reopened skin tears and an allegation by a cognitively impaired, blind resident that a staff member struck him. In both cases, intakes were submitted to the state agency, but no provider investigation reports were available. Interviews with staff revealed a lack of familiarity with official reporting requirements and an inability to locate investigation documentation. The facility's own Abuse Prevention Program policy requires thorough investigation and timely reporting, but these procedures were not followed in the cited cases.