Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to follow its policy and procedures for reporting a reasonable suspicion of a crime, specifically regarding the immediate reporting of an allegation of staff-to-resident physical and verbal abuse. A resident with mildly impaired cognition and significant care needs reported to a third-party Clinical Evaluator that he was held down by five staff members and subjected to verbal aggression. The Assistant Director of Nursing (ADON) was informed of the allegation and notified the Director of Nursing (DON) and the Administrator (ADM) within minutes. However, the ADM stated that the incident had already been investigated and did not ensure that the allegation was immediately reported to the State Agency and local law enforcement as required by both facility policy and state regulations. Record review and interviews confirmed that the facility's policy required immediate reporting of any alleged or suspected abuse, neglect, or exploitation. Despite this, the ADM relied on a prior investigation and did not report the new allegation in a timely manner. This failure to report could have delayed necessary protective actions for residents, as the required notifications to authorities were not made within the mandated timeframe.