Failure to Timely Report Alleged Physical Abuse by Family Member
Penalty
Summary
The facility failed to ensure that an allegation of physical abuse involving a resident and her responsible party (RP) was reported to the State Survey Agency within the required timeframe. On 3/29/25, a certified nursing assistant (CNA) witnessed the RP slap the resident in the face during a transfer while the resident was agitated and combative. The CNA immediately reported the incident to a licensed vocational nurse (LVN), who then notified the Director of Nursing (DON) and the Administrator. Despite this, the incident was not documented in the facility's incident log for March 2025, nor was it reported to the State Survey Agency (HHSC) or law enforcement as required by regulation. The resident involved was an 81-year-old female with severe cognitive impairment (BIMS score of zero), dementia, and a history of incontinence and limited mobility, requiring maximum assistance for transfers and care. Skin assessments and vital signs following the incident showed no physical injuries or abnormalities, and the resident did not express pain or psychosocial harm during subsequent interviews. However, the resident was unable to clearly recall or respond to questions about the incident due to her cognitive status. Multiple staff interviews confirmed knowledge of the abuse allegation and awareness of mandatory reporting requirements. The social worker, LVN, DON, and Administrator all acknowledged that the incident was reportable to the State Survey Agency and potentially to law enforcement. Despite this, the facility did not report the allegation within the required two-hour window, and the internal investigation remained incomplete as of the survey date. The facility's own policy also required immediate reporting of such incidents, which was not followed in this case.