Failure to Submit and Retain Required Abuse and Neglect Investigation Reports
Penalty
Summary
The facility failed to provide evidence that all alleged violations of abuse, neglect, and exploitation were thoroughly investigated and that the results of these investigations were reported to the State Survey Agency within five working days, as required. This deficiency was identified for six out of eight residents reviewed for abuse, neglect, and exploitation. Specific incidents included allegations of rough care during activities of daily living (ADL) assistance, rough care during medication pass, failure to provide essential care, resident-to-resident physical altercation, and concerns of possible sexual assault and unsanitary conditions. In each case, the facility did not submit the required five-day investigation findings via the TULIP database, and no additional information related to the incidents was found in the system. For example, two residents with self-care deficits and intact cognition reported that a CNA was rough during ADL care, but the facility did not identify the CNA in documentation, nor did it submit a five-day investigation report. Another resident's family member alleged rough care during medication administration, but again, no five-day investigation findings were submitted, and documentation was lacking regarding the incident details and staff training at the time. In a separate case, a resident's responsible party alleged that a CNA failed to provide essential care, but the facility did not submit the required investigation findings, and the CNA could not recall the details of the incident. Additional incidents included a resident hitting another resident, with both residents having behavioral health diagnoses and care plans addressing aggression and psychotropic medication management. Despite assessments and interventions being documented in the clinical record, the facility did not submit the required five-day investigation findings. Another case involved an allegation of possible sexual assault, lack of catheter dressing, and unsanitary room conditions, reported by an insurance provider, but again, no five-day investigation findings were submitted. Staff interviews confirmed awareness of abuse and neglect training, but the required documentation and reporting of thorough investigations were not completed or retained as required by facility policy and regulation.