Failure to Report Resident Abuse Allegation to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse made by a resident was reported to the state agency as required. A cognitively intact resident with multiple medical diagnoses, including COPD, diabetes, CVA, seizure disorder, anxiety, depression, bipolar disorder, and asthma, reported that after winning a meal through a facility lottery, an LPN took her meal away in the dining room and directed her to eat in her room. The resident described the LPN's actions as abusive, particularly the act of snatching the meal, and stated that this caused her significant distress. A CNA who witnessed the interaction described the LPN's tone as rude and disrespectful, though did not see the meal being physically taken away. The CNA later reported the incident to the DON, who stated she would look into it and clarified that residents could eat any meal in the dining room. Despite the resident's allegation and the CNA's report to the DON, the incident was not documented in the progress notes, nor was it reported to the state agency as required by facility policy. The Administrator confirmed during interview that she was unaware of the allegation and acknowledged that it should have been reported. Facility policy mandates immediate reporting of all allegations of abuse to the Administrator and the state agency within 24 hours, but this procedure was not followed in this case.