Failure to Immediately Report and Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure that staff immediately reported allegations of abuse to administration and did not conduct thorough investigations into reported incidents. In one case, a resident with Parkinson's disease, COPD, and depression, who was cognitively intact and dependent on staff for care, reported that a CNA was aggressive during a mechanical lift transfer, left the resident in bed with an open incontinence brief and the lift pad still underneath, and did not return to assist further. The incident was not reported to administration or a supervisor until the following day, and the subsequent investigation lacked witness statements from the resident's roommate, other staff on shift, and the coworker who assisted with the transfer. In another instance, a cognitively intact resident with multiple medical conditions, including anemia and heart failure, reported feeling rushed and mistreated during a mechanical lift transfer by a CNA and an LPN. The investigation into this allegation was incomplete, missing critical documentation such as the date, time, and identity of the person providing the statement, as well as witness statements from the involved staff, other staff on shift, and the resident's roommate. Interviews with facility leadership confirmed that in both cases, the allegations were not reported immediately as required by facility policy, and the investigations did not include all necessary witness interviews or complete documentation. The facility's policy mandates immediate reporting of abuse allegations and comprehensive investigations, including interviews with all relevant parties, which was not followed in these incidents.