Failure to Report Allegations of Abuse and Neglect to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report potential allegations of abuse and neglect to the State Agency (SA) for three residents whose cases were reviewed. For one resident with ALS who was cognitively intact and dependent on staff for all ADLs, a grievance log and incident reports showed that the resident alleged a staff member did not place their eyeglasses on as requested, instead holding them out of reach for a couple of minutes before setting them on a table and leaving the room. The resident expressed concerns about how the staff member treated them and requested that this staff member no longer provide their care. The Social Services Director later learned, via an email from a community health reporter, that the resident had complained that staff did not know how to care for a person with ALS, did not feel cared for or safe, and felt staff did not know how to manage episodes of choking or position their head upright. Although this concern was investigated internally, the facility’s reporting log showed that this potential allegation of abuse and/or neglect was not entered into the reporting log and was not reported to the SA. A second deficiency component involved another resident with dementia and Parkinson’s disease, who was cognitively intact and required substantial to maximum assistance with toileting and dressing and was frequently incontinent of urine. A grievance form documented that the resident’s representative reported finding the resident in their wheelchair with dried toothpaste on their shirt, pants, and face, and that when they assisted the resident to the dayroom, the resident was so wet with urine that a trail of urine was left down the hallway. The representative stated they wanted the resident treated with dignity. This concern, which constituted a potential allegation of neglect, was handled as a grievance within the facility. Review of the reporting log showed that this potential allegation of neglect was not reported to the SA. The third component of the deficiency involved a resident with heart failure and depression, who was cognitively intact, independent with toilet transfers, and required substantial to maximum assistance with toileting hygiene. A grievance form documented that the resident reported being upset with the way a nursing assistant spoke to them, blaming them for locking a shared bathroom door and saying, “Would you stop locking the dang door?” The resident stated that the way they were spoken to was unprofessional and unnecessary. This concern, a potential allegation of verbal abuse, was investigated as a grievance rather than as an allegation of abuse. Review of the reporting log showed that no potential allegation of abuse for this resident was reported to the SA. In an interview, the DON stated they did not report the concerns for two of the residents as allegations of abuse or neglect because they did not believe the staff actions were purposeful or willful.
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