Failure to Timely Report and Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately to the Administrator, as required by policy. An incident occurred in which a certified nursing assistant (CNA) attempted to transfer a female resident with significant cognitive impairment and multiple comorbidities, including dementia, malnutrition, anxiety, depression, and bipolar disorder, without using a gait belt as required by the resident's care plan. During the transfer, the resident leaned to the right and hit her shoulder and neck on the bedrail. The CNA did not report the incident to the nurse, and no incident or accident report was completed for this event. The incident was only brought to the facility's attention after the resident's family member observed the event via surveillance camera and contacted the facility, expressing concern that the resident may have sustained injuries. The nurse on duty was not aware of the incident until contacted by the family and subsequently notified the DON and physician, who ordered a STAT x-ray. The x-ray revealed no acute injury, but the event was not documented in the facility's incident or grievance logs, and the Administrator was not made aware of the situation until it was reviewed during the survey. Interviews with staff confirmed that the CNA did not report the incident as required, and the DON did not initiate an investigation or further action after being informed by the family. The facility's policies require immediate reporting and investigation of all alleged abuse or incidents, but these procedures were not followed. The failure to report and investigate the incident placed residents at risk of injuries and neglect of care.