Failure to Timely Report and Retain Abuse Investigation Results
Penalty
Summary
The facility failed to ensure that the results of an investigation into an abuse allegation were reported in a timely manner to the State Agency, as required. A resident, who had no cognitive impairment, reported to social services that a CNA was rough with him during care, causing pain and subsequent difficulty urinating. The incident was reported to the appropriate authorities, and the CNA was suspended and reassigned. However, when surveyors requested the investigation summary, the current Director of Nursing and Administrator were unable to locate the investigation documents, stating that the facility had transitioned to a new company and the records were left by the previous administration. Interviews with former administrative staff confirmed that the investigation was conducted and the abuse allegation was reported, but the specific investigation notes and summary could not be found. The current administration searched for the documents without success and could not confirm if the required 5-day investigation report was sent to the State Agency. The facility's policy required the use of an abuse investigation process as mandated by law, but the relevant policy and procedure for reporting investigation notes or summaries was not available in the provided documentation.