Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to investigate and report an allegation of abuse involving a resident who had a history of cognitive impairment and multiple bruises upon admission. The resident, who had a diagnosis of unspecified dementia and a fluctuating BIMS score indicating periods of moderate cognitive impairment, was noted to have significant bruising on her legs and hips, reportedly from a fall at home prior to admission. During her stay, the resident and her daughter expressed concerns to staff about rough treatment by an unidentified female staff member during overnight shifts, particularly when the resident was being turned or cleaned due to C-diff-related loose stools. Staff interviews revealed that the concerns about rough handling were communicated to at least one LPN, who reported the information to the charge nurse. However, there was no documentation or evidence that a formal assessment or investigation was initiated in response to these allegations. The charge nurses and other staff interviewed either did not recall receiving such reports or stated that no further action was taken. The facility's policies required that any suspected abuse be reported, investigated, and, if necessary, reported to the state agency, but this process was not followed in this case. Despite the facility's policies and the statements from staff and administration outlining the required procedures for handling abuse allegations, there was no indication that the incident involving the resident's report of rough treatment was investigated or reported to the state agency. The lack of documentation and follow-up on the reported concerns constituted a failure to respond appropriately to an alleged violation, as required by facility policy and regulatory standards.