Failure to Complete and Submit Required Five-Day Investigation Reports
Penalty
Summary
The deficiency involves the facility’s failure to report the results of abuse/neglect-related investigations to appropriate officials within five working days, as required by its own policy and state law. The facility’s Abuse, Neglect & Misappropriation policy states that accurate and timely reporting of alleged and substantiated incidents must be sent to officials, including OHFLAC, APS, the Regional Ombudsman, and other authorities, and that investigation results must be reported within five working days of the incident. For one resident, who reported falling during a CNA-assisted transfer and sustaining a femur fracture, the DON was unable to provide the initial reportable or the required five-day follow-up for two separate falls, and the resident’s care plan was not updated for either fall. The DON later stated that the social worker had been terminated for not completing the reportable or the five-day follow-up related to this resident’s fall. Another resident, who was cognitively intact per a BIMS score of 14, reported that another resident entered her room, hit her, and frequently came in and took things. The resident told the SW she felt fearful during the incident and uneasy at times with the other resident who wandered. There was no documentation of grievances, concerns, or reportables related to this incident, and the DON stated the incident was not reported because the resident later stated she felt safe in the facility. In a separate facility-reported incident involving another resident, the DON stated that the former NHA had been responsible for reporting FRIs and acknowledged there was no evidence that the required five-day follow-up report to the state agency had been completed. These findings show multiple instances where the facility did not complete or submit the mandated five-day investigation results to the appropriate officials.
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