Failure to Investigate and Report Allegations of Abuse, Neglect, or Exploitation
Penalty
Summary
The facility failed to thoroughly investigate and report allegations of abuse, neglect, or exploitation (ANE) to the State Survey Agency within the required 5 working days for two residents. In the first case, a resident with a documented Do Not Resuscitate (DNR) order was subjected to CPR by a nurse, despite clear documentation and communication of the resident's DNR status. Staff interviews revealed that the nurse initiated compressions before being informed of the DNR status, and there was no subsequent investigation or report of this incident to the state agency. The Assistant Director of Nursing (ADON) acknowledged awareness of the code status incident but did not report it, and the previous Director of Nursing (DON) stated she was unaware of the event and would have reported it if informed. In the second case, a resident's representative made multiple allegations of neglect via text messages and emails to the previous Administrator and DON, including concerns about delayed pain medication, lack of recognition of significant changes in the resident's condition, and inadequate response to requests for care. Despite these communications, there was no evidence that the facility investigated these allegations or reported the results to the state agency. The DON and Administrator at the time received and acknowledged the complaints but did not initiate the required investigation or reporting process. Record reviews confirmed that no facility-generated reports regarding these allegations were submitted to the state agency during the relevant periods. Interviews with current and former staff indicated a lack of clarity and follow-through regarding responsibility for investigating and reporting ANE allegations. The facility's own policies required immediate investigation and reporting of such incidents, but these procedures were not followed in the cases reviewed.