Failure to Report Alleged Physical Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident with severe cognitive impairment and significant assistance needs for activities of daily living. The resident, who had diagnoses including osteoarthritis and rheumatoid arthritis, reported to the Assistant Director of Nursing (ADON) that a Certified Nurse Assistant (CNA) was rough with her while providing personal care. The resident's family member also reported the incident to staff and provided a photograph of the CNA involved. Despite these reports, the ADON did not report the allegation to the required authorities, stating that she did not consider the incident abuse because the resident said she was fine. Interviews with other staff, including another CNA and the Director of Staff Development (DSD), confirmed that being rough with a resident is considered a form of abuse and should be reported and investigated immediately. The Director of Nursing (DON) acknowledged that the allegation should have been reported and investigated, but at the time, it was not considered abuse. A review of the facility's abuse reporting policy indicated that all allegations of abuse must be promptly reported to the appropriate agencies, including the state licensing agency, the Ombudsman, and law enforcement, which was not done in this case.