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F0609
D

Failure to Timely Report Alleged Abuse and Notify Authorities

Shawano, Wisconsin Survey Completed on 05-20-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an allegation of abuse involving involuntary seclusion in a timely manner to the State Agency (SA) and did not notify the local police department as required. A Certified Nursing Assistant (CNA) reported to the Nursing Home Administrator (NHA) that another CNA had barricaded a resident behind the nurses' station using a treatment cart, restricting the resident's movement. This incident was observed when the reporting CNA arrived for their shift and found the resident unable to leave the area without assistance. The resident was also found to have blood and bruising on the left lower leg, which was reported to a Registered Nurse (RN) and treated at that time. Staff interviews and record reviews revealed that the incident was initially reported to the NHA and Director of Nursing (DON) on the same day it occurred, and statements were collected from involved staff. Despite being aware of the allegation and recognizing that involuntary seclusion constitutes abuse, the NHA and DON did not report the incident to the SA until several days later. The CNA accused of the action continued to work during this period, and the facility did not notify the local police department about the allegation. The facility's own Abuse Prevention Program required immediate reporting of abuse allegations to the Administrator or designee, and to the SA and other authorities within specified timeframes. However, the NHA and DON delayed reporting because they believed the incident did not constitute abuse based on their internal investigation. The delay in reporting and failure to notify law enforcement were identified as deficiencies during the survey.

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