Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the state survey agency as required by its own policy and federal regulations. A resident with severe cognitive impairment, aphasia, and hemiplegia reported to therapy staff that a geriatric nursing assistant hurt their arm during care. The Director of Social Work (DSW) interviewed the resident, who described the incident as the table hitting their arm during care, but was unclear if it was intentional or accidental. The DSW also interviewed the assigned staff and other residents, found no additional concerns, and provided the information to the Administrator. However, the incident was not reported to the state survey agency because the DSW and Administrator believed it was accidental and not abuse. Multiple staff interviews confirmed that the resident initially alleged rough treatment by staff, but later changed their account, suggesting the injury may have been accidental. Despite this, the Director of Rehabilitation reported the allegation as required, but was unaware if it was escalated to the state. The Administrator later acknowledged that the resident's statement should have been considered an allegation of abuse and reported, but this was not done at the time. The facility maintained internal documentation of the incident but did not fulfill the mandatory reporting requirement.