Failure to Investigate and Report Abuse Allegation
Penalty
Summary
The facility failed to complete a thorough investigation and report findings within five working days for an allegation of abuse involving one resident. The resident filed a grievance stating that a nurse spoke to him rudely regarding his request for additional pain medication, telling him she could only provide Tylenol, and reported that this nurse had been rude since his admission. The resident also reported witnessing the same nurse threaten another resident. The grievance, dated 10/13/25, was not entered on the facility’s incident report list covering 10/31/25 through 12/12/25, indicating that no incident investigation or report was completed for this allegation. During subsequent interviews, the resident stated he no longer had concerns about pain medication but confirmed the nurse’s prior rude behavior made him feel bad. The nurse identified in the grievance reported she was unaware a grievance had been filed and that management had never discussed the incident with her. The DON stated she was out of town on the date of the grievance but would have expected management to investigate the allegation. The unit manager recalled the grievance but acknowledged he did not conduct an investigation and was unaware of any outcome. The social services director reported she had given the grievance to the unit manager for investigation but did not follow up. The administrator confirmed that the allegation of abuse was not thoroughly investigated or reported to the State Agency as required.
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