Failure to Investigate Allegation of Rough Care and Mistreatment
Penalty
Summary
The facility failed to provide evidence that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one resident. A resident with a history of chronic medical conditions, including COPD, depression, and morbid obesity, reported to the Licensed Social Worker (LSW) that a CNA was rough during perineal care, did not stop when asked, and made fun of her. The resident described specific actions by the CNA, such as improper placement of a brief, rough handling, and mocking gestures. The LSW documented the grievance and reported it to the Administrator, as per facility protocol. However, there was no evidence that the facility conducted a thorough investigation into the resident's allegations. The Administrator acknowledged receiving the grievance but did not report the incident to the state or conduct further investigation, citing the resident's history of false reporting and satisfaction with the resolution of not having the CNA assigned to her care. The facility's records and interviews confirmed that no self-reported incidents were filed, and the facility's policy on abuse and neglect investigation was not followed in this case.