Failure to Report Allegation of Rough Care and Mistreatment to State Agency
Penalty
Summary
The facility failed to report an allegation of mistreatment to the State Agency and did not follow its abuse prohibition policy for one resident. A grievance completed by a Social Services Technician documented that the resident’s son reported his mother felt staff were being rough with her, including pulling her hair and legs, and that she had a current cut on her leg. The grievance also documented that the resident was fearful of retaliation from staff. The resident had been admitted with acute respiratory failure, macular degeneration, and conductive hearing loss, had a BIMS score of 8 indicating moderately impaired cognition, and required staff assistance for all ADLs. During interviews, the Administrator, who also served as the facility’s abuse coordinator, stated they were unaware of the rough care and mistreatment allegation and acknowledged that it should have been reported. The Social Services Technician reported that they had informed the Administrator of the concern. The facility’s Abuse Prohibition Policy required staff to report any allegations or suspicions of mistreatment and injuries of unknown source to the Administrator and DON immediately, and required the Administrator or designee to notify State or Federal agencies of allegations per state guidelines (within 2 hours for abuse or serious injury, and all others within 24 hours). This required reporting to the State Agency did not occur for this allegation.
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