Failure to Report and Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the State Agency, did not complete an investigation, and did not submit the investigation within the required 5 working days. According to the facility's Abuse and Neglect Policy, all alleged or suspected violations, including abuse, neglect, or injuries of unknown origin, were to be reported immediately to the Administrator and to the State Survey and Certification Agency within 5 working days. However, a review of facility records and interviews revealed that an incident involving a resident's call light being removed from their reach by a nurse aide was reported to the Administrator but was not reported to the State Agency, and no investigation was completed or submitted as required. The resident involved had multiple medical conditions, including heart failure, previous stroke with paralysis, sepsis, obstructive uropathy, anxiety, depression, and diabetes, and required total staff assistance for most activities of daily living. The resident and their spouse reported that it was common for staff to remove the call light from the resident's reach, and specifically recounted an incident where a nurse aide removed the call light after the resident requested assistance. The Director of Nursing confirmed that the facility did not report the allegation or complete and submit the required investigation to the State Agency.