Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to identify and report potential allegations of abuse and neglect to the State Survey Agency as required by policy and regulation. For one resident with a history of stroke and depression, who required maximum assistance with activities of daily living, a grievance was filed alleging that a male CNA was rough while dressing the resident, resulting in a bruise on the resident's arm. This allegation was investigated as a grievance but was not logged or reported to the State Survey Agency as a potential abuse incident. Another resident, admitted with a spinal fracture and depression and dependent on staff for toileting, reported being left in a soiled brief after a nursing assistant refused to provide care, stating it was not their section and the assigned aide was on break. This allegation of neglect was also investigated as a grievance and not reported to the State Survey Agency. The Director of Nursing Services confirmed that neither incident was logged or reported as required.