Failure to Report and Document Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to implement its abuse prohibition policy by not identifying and reporting all allegations of abuse and neglect as required. A review of the facility's policy indicated that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property were to be reported immediately to the executive director, who would then notify the appropriate agencies. However, a review of grievance forms over a 12-month period revealed multiple allegations of abuse and neglect that were not reported as required by the policy. Specific incidents included residents and their families reporting concerns such as staff yelling at residents, residents being left in soiled clothing or bedding, delayed responses to call bells, rough handling during care, and possible misappropriation of property. Other grievances involved residents being left unattended, not being changed in a timely manner, and staff being loud or unprofessional during night hours. In one case, a resident reported another resident entering her room and physically grabbing her, while another resident's family expressed concern over unexplained bruising. A review of the facility's reportable log for the same period found that none of these allegations had been documented or reported as required. During an interview, the Nursing Home Administrator confirmed that if the allegations were not on the log, they had not been reported, and agreed that the incidents should have been reported. The administrator assumed that the social worker had completed the reporting, but this was not the case.