Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to identify and report accusations of abuse and/or neglect by staff to the State Survey Agency for three of seven sampled residents. In one case, a resident complained about not being repositioned throughout the night, and a family member raised concerns regarding missed medication administration and catheter care. These concerns were documented in progress and physician notes, but staff confirmed that no report was made to the State Survey Agency regarding these allegations of neglect. Additionally, grievances were filed by two other residents: one reported being hurt by a night CNA during care, and another, who was being treated for a recently fractured arm, reported pain when a staff member pulled his arm during a transfer. Both of these allegations, which could indicate potential abuse or neglect, were not reported to the State Survey Agency as required by facility policy. Staff interviews confirmed that these accusations should have been reported and investigated, but this did not occur.