Failure to Investigate and Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate and report alleged violations of abuse or neglect involving three residents. One resident reported being hurt by a staff member during care, and another resident with a fractured arm complained that a staff member hurt his arm during a transfer. Grievance records for both residents did not show evidence that these events were investigated or reported to the State Survey Agency as potential abuse or neglect. Additionally, a third resident with pressure ulcers and a care plan requiring frequent repositioning complained of not being repositioned all night. This resident's family also raised concerns about missed administration of prescribed vaginal cream and lack of catheter care, despite physician orders for both interventions. Interviews with staff confirmed that these complaints and allegations were not reported to the State Survey Agency or investigated as required. The facility's policy mandates review and investigation of grievances, complaints, and allegations of abuse or neglect, but records and staff interviews indicated that these procedures were not followed for the incidents involving the three residents.