Failure to Report Alleged Physical Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident with severe cognitive impairment and multiple diagnoses, including dementia and a recent clavicle fracture. The resident, who was dependent on staff for most aspects of care, was admitted, readmitted, and later discharged to the hospital following an incident where she claimed to have been pushed from her wheelchair by staff. The allegation was communicated to facility leadership via an email from the Transitional Care Liaison, which included a hospital case manager's note stating that the resident's son found her story inconsistent but agreed to a report being made to Adult Protective Services (APS). Despite being notified of the abuse allegation, the facility did not report the incident to the State Agency as required by both federal regulations and the facility's own policy, which mandates immediate reporting of all abuse allegations. During an interview, the Administrator acknowledged the decision not to report, stating that the team felt the incident did not occur. Facility documentation confirmed that the abuse allegation was not reported to the State Agency, constituting a failure to follow established procedures for reporting alleged violations.
Plan Of Correction
Element 1 - The facility identified resident #803 and they no longer reside at the facility. The administrator during this survey is no longer employed at the center effective 6/19/2025. Element II - The facility identified that all residents residing at the center could be affected by the deficient practice. The facility interviewed all patients who can be interviewed (BIMS>11), to ensure that any potential abuse allegations have been reported. There were no findings to report. Element III - The new facility administrator reviewed and understands the reporting requirements of the abuse policy. The facility educated the transitional care staff on proper abuse reporting methods to promote timely abuse reporting. Element IV - The facility administrator/designee will conduct 3 random interviews, weekly, times four weeks to ensure that all abuse allegations have been identified and reported. The results from those interviews will be submitted to the QAPI committee for review and recommendation. Element V - The administrator is responsible for achieving and maintaining compliance. The compliance date is 7/15/25.