Failure to Timely Report Alleged Abuse and Protect Resident from Family Member
Penalty
Summary
The facility failed to immediately report an allegation of abuse to the state agency as required by its own policy and federal regulations. A resident with a history of confirmed physical abuse, major depressive disorder, and anxiety disorder was admitted to the facility after being abused by a family member. Despite clear documentation that the resident did not want contact with the alleged abuser and that the abuser was the subject of an open Adult Protective Services (APS) case, the facility did not report subsequent incidents of potential mental and verbal abuse by the same family member to the state agency within the required timeframe. On two separate occasions, the family member entered the facility and attempted to visit the resident against her wishes. During the second incident, the family member became hostile, pushed past staff, and attempted to enter the resident's room while she was receiving personal care, causing the resident visible distress, fear, and anxiety. Staff and police intervention were required to remove the family member from the premises. Documentation from staff, including the case manager and LVN, described the family member's actions as verbally and emotionally abusive, and noted the resident's significant emotional response, including the need for anti-anxiety medication. Despite these events, the facility's abuse coordinator (administrator) did not conduct a thorough investigation or report the incident to the state agency, citing a lack of complete information from staff and a belief that the incident was a family dynamic rather than abuse. The administrator acknowledged that, according to facility policy, such incidents should be reported and investigated as potential abuse, but this was not done. The resident was not offered a room change for her safety after either incident, and the administrator did not speak directly with the resident about the events.