Failure to Timely Report Allegation of Verbal Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to the State Licensing Agency as required by its own policy. The policy mandates that all allegations of abuse be reported immediately, but not later than two hours after the allegation is made. In this case, a resident with no cognitive impairment, who required significant assistance with activities of daily living, reported that a CNA made a derogatory comment during care. The resident stated the incident was reported to the Administrator in Training (AIT) on the same day it occurred. Interviews and record reviews confirmed that the AIT, Director of Nursing (DON), and Administrator were all made aware of the allegation. The DON conducted an internal investigation, including interviews and witness statements from the CNAs involved, and concluded that the comment was not directed at the resident but was part of a conversation between staff members. Despite this, the facility did not report the allegation to the State Licensing Agency as required by policy, because the DON and Administrator determined it was not abuse after their internal review. Further interviews revealed inconsistencies in the notification process and documentation, with the Administrator and CNA involved indicating they were not immediately informed or did not recognize the need to report the incident externally. The failure to report the allegation, regardless of the internal findings, constituted noncompliance with the facility's abuse reporting policy and regulatory requirements.