Failure to Report Alleged Physical Abuse to Abuse Coordinator and State Agency
Penalty
Summary
The facility failed to notify the Abuse Coordinator and the State Agency of allegations of physical abuse involving two residents with intact cognition. One resident reported being hit on the head and face by another resident, though she could not recall the exact date. Another resident stated she was hit on the head four times by the same resident, resulting in a headache for two days. This incident was witnessed by two CNAs, and the resident reported it to two Psychiatric Rehabilitation Services Coordinators. Despite these reports, the allegations were not communicated to the Abuse Coordinator as required by facility policy. Staff interviews revealed that while some staff believed they had reported the incidents to appropriate personnel, the Abuse Coordinator and the State Agency were not notified. The facility's guidelines require immediate reporting of any suspected abuse to the administrator or an immediate supervisor, who must then inform the administrator. However, the chain of command was not followed, and the required notifications and investigations were not initiated in a timely manner.