Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
A deficiency occurred when facility staff failed to report an allegation of abuse involving a resident with dementia, anxiety, osteoarthritis, and hypertension. The resident, who had a history of cognitive impairment and required moderate to substantial assistance with activities of daily living, was found with a large, dark bruise on her left forearm after a visit from her husband. Multiple staff members documented and reported that the resident stated her husband, whom she sometimes referred to as her brother due to her dementia, had grabbed her arm and caused the bruise during an episode where he admitted to losing his temper. Staff also noted that the resident's husband had previously been involved in incidents that led to her admission to the facility. Despite staff promptly notifying administrative personnel of the incident and expressing concerns of possible abuse, the administrative staff member on call instructed them not to document the event or file incident reports, expressing disbelief in the abuse allegation. The administrative staff member did not assess the resident, did not initiate an investigation at the time, and did not report the incident to the State Agency or law enforcement within the required two-hour window. Staff members reported feeling fearful of job loss or retribution if they did not comply with these instructions. The facility's own policy required immediate reporting of any suspicion of abuse resulting in significant injury to the State Agency and law enforcement. However, the administrative staff member failed to follow this policy, and the event was not reported as required. The lack of timely reporting and investigation left the resident at risk for unidentified and ongoing abuse or mistreatment, as documented by the surveyor's findings and staff witness statements.