Failure to Timely Report Investigation Results of Suspected Abuse, Neglect, or Misappropriation
Penalty
Summary
The facility failed to ensure that the results of all investigations into suspected abuse, neglect, or misappropriation were reported within five working days to the administrator or designated representative and to other officials as required by State law. For one resident, who was cognitively intact and had a history of chronic obstructive pulmonary disease, asthma, and malignant neoplasm, a grievance was filed by the resident and her son regarding missed nebulizer treatments. They reported that treatments were not administered as ordered, and that records falsely indicated administration. There was no evidence that the results of the investigation into this grievance were reported to the appropriate authorities within the required timeframe. For another resident with heart failure and severe dementia, who was on 1:1 observation due to behavioral concerns, a nursing note documented unexplained bruising. The facility's investigation did not provide a documented explanation for the bruising, and there was no evidence that the injury of unknown origin or the results of the investigation were reported to the State Survey Agency as required. These findings were confirmed through interviews with facility leadership and review of facility documentation and policies.