Failure to Identify and Report Alleged Abuse
Penalty
Summary
The facility failed to identify and report an allegation of abuse involving one resident who was admitted for skilled nursing and rehabilitation following a recent hospitalization. The resident, who had a history of stroke, back surgery, and an implanted nerve stimulator, reported that a CNA was rough during personal care, including yanking the resident up and down and not listening to requests to stop. The resident described feeling like a 'rag doll' and reported bruising as a result of the rough care. The incident was reported by the resident to a provider the following morning, and subsequently discussed with the Director of Nursing Services (DNS). Despite the resident's report and a grievance form documenting the allegation of rough care, the facility did not log the incident as an abuse allegation in the incident logs. There was no documentation in the electronic health record of a provider note, skin assessment, or evaluation following the resident's report. The DNS documented that education would be provided to the CNA and updated the resident's care plan, but there was no evidence of an abuse investigation or required notifications to authorities as outlined in facility policy and state guidelines. Interviews with multiple staff members revealed inconsistent understanding and implementation of abuse reporting protocols. Some staff indicated they would notify supervisors or complete grievance forms, but were unclear about the process for suspending staff or notifying authorities. The DNS stated that further information would be gathered before suspending staff or notifying parties, and could not recall the staff member involved or provide documentation of the education provided. The administrator confirmed that either the administrator or DNS would decide next steps upon being notified of such incidents.