Failure to Timely Report and Document Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to timely report allegations of abuse, neglect, or misappropriation of property to the State Agency and failed to document and investigate these allegations in its incident logs for three residents. One resident with dementia and a need for assistance with personal care reported that another resident repeatedly entered her room, took her nice clothes, and that some clothing sent to laundry never returned. She stated she had informed staff about the intrusions and missing items and indicated that the other resident had again entered her room on the day of the initial interview. In a later interview, she reported that the same resident entered her room around 4:00 a.m., took a pillow from the other bed, and that she called the nurse, who removed the other resident from the room. Despite the administrator being informed of these allegations, there was no corresponding documentation in the incident logs for the months reviewed, and the allegation was not reported to the State Agency as required by the facility’s Purple Book guidelines. Another resident with dementia, gait and mobility abnormalities, and a need for assistance with personal care reported during a documented interview that care from male staff was “a little rough,” specifically mentioning that men were a little rough getting him out of bed. This statement was recorded by the Social Services Coordinator/Assistant, who had been trained on abuse and neglect, but no investigation was initiated, and the allegation was not reported to nursing staff or entered into the incident log. The Social Services staff member acknowledged that the allegation was not reported to nursing, and the interim DON and interim administrator confirmed that the February incident log did not contain this resident’s allegation and that no investigation had been completed. Overall, the facility did not follow its stated responsibilities to report all suspected incidents of abuse, neglect, financial exploitation, or misappropriation of property, to notify the State Hotline immediately or once the resident was protected, and to log such incidents in the state reporting log.
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