Failure to Report and Complete Abuse Investigations Within Required Timeframes
Penalty
Summary
The deficiency involves the facility’s failure to report allegations of abuse to Adult Protective Services (APS) and law enforcement, and failure to submit the results of abuse investigations to the State Agency (SA) within 5 working days for two residents. For one resident with a history of a displaced intertrochanteric fracture of the left femur, osteoporosis, and chronic pain, the care plan identified risk for ADL self-care performance deficit and encouraged participation in care. This resident was admitted after a ground level fall at home and later sustained a fall in the facility, after which he was found on the floor by the toilet, alert and oriented, and able to describe the event. On the same day, documentation showed the resident expressed unhappiness with the facility and, in a late entry incident note, reported being treated roughly and refusing further care from a specific CNA. The initial facility report to the SA for this resident stated that he told an unnamed therapist he did not want care from a CNA assigned that day, alleging that this CNA had caused at least three broken bones, was going to kill him, and was out to get him. He provided a physical description of the CNA, and the facility identified a CNA who best fit that description. The resident further alleged that the CNA wheeled him too fast, bumped his feet on walls, made him feel like a horse while being showered, and that he hit his face on the wall while being turned during care. The CNA was immediately suspended, and the report indicated the facility was contacting other agencies. However, review of the clinical record and facility documentation revealed no evidence that this allegation was reported to law enforcement or APS, and no evidence that the results of the investigation of the alleged abuse were submitted to the SA within 5 working days of the incident. For the second resident, admitted with chronic embolism, hemiplegia and hemiparesis, restless leg syndrome, and other specified brain disorders, the ADL care plan also identified risk for ADL self-care performance deficit and included interventions to praise self-care efforts and encourage participation. Documentation showed the resident was alert and oriented, with psychology notes indicating no evidence of psychological harm related to an unspecified incident the prior week and no concerns or changes since that occurrence. An initial facility report to the SA later documented that this resident reported to the executive director that another resident made sexual comments toward her while she was sitting on the smoking patio. Despite this allegation of sexual comments by another resident, review of the clinical record and facility documentation showed no evidence that the allegation was reported to law enforcement, and no evidence that the results of the investigation of the alleged abuse were submitted to the SA within 5 working days of the incident.
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