Failure to Submit Required 5‑Day Abuse Investigation Report
Penalty
Summary
The deficiency involves the facility’s failure to submit an abuse investigation report to the State Survey Agency within 5 working days for an allegation involving one resident. The resident had diagnoses including depression, schizophrenia, quadriplegia, and hypertension, and a recent MDS showed a BIMS score of 10, indicating moderately impaired cognition. A behavior charting assessment documented that the resident became very upset and physically and verbally aggressive with staff. On the date of the incident, documentation in a suspected abuse investigation report indicated that the resident attempted to run into staff and other residents with an electric wheelchair in a common area, a CNA positioned themself in front of the wheelchair, the resident kicked the CNA, and the CNA then placed the resident into a recliner while yelling loudly. The investigation concluded that the CNA’s loud complaining and raised voice were not appropriate in a behavioral setting. Surveyors requested the facility’s 5‑day investigation report for this abuse allegation, but the facility was unable to provide it. Review of the clinical record showed no evidence that the incident investigation report was submitted to the State Agency within 5 working days. Interviews with the DON and the administrator confirmed that facility policy and practice require immediate initiation of an abuse investigation, separation of the resident and staff, notification to the State Agency within 2 hours, and submission of a detailed investigation report within 5 working days. The administrator specifically stated that the facility did not have any 5‑day investigation report for the abuse allegation between the CNA and the resident. Review of the facility’s written policy on identification and investigation of abuse, neglect, misappropriation, and injuries of unknown origin confirmed that investigations must be completed within five working days, with limited exceptions, underscoring that the required 5‑day report was not completed or submitted in this case.
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