Failure to Timely Report Allegations of Abuse and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to report allegations of abuse involving three residents to the Abuse Coordinator as required by policy. One resident, who was moderately cognitively impaired and diagnosed with mild intellectual disabilities, consistently reported that a female CNA had thrown her against a wall, causing her to hit her head. The resident relayed this allegation to multiple staff members, including a hospice RN and an LPN, but the information was not reported to the Administrator or properly escalated internally. Staff interviews revealed confusion about the identity of the alleged perpetrator and a lack of clarity regarding reporting responsibilities. Internal reporting of the abuse allegation only occurred after the State Agency surveyor brought it to the Administrator's attention. Additionally, two other residents who were previously roommates were involved in an unreported incident where one resident allegedly hit the other. Staff members were aware of rumors or gossip about the incident, and one resident confirmed being hit by her former roommate, though she denied being physically hurt. There was no documentation in the progress notes regarding this potential physical altercation, and no internal report was made until the State Agency surveyor informed facility leadership. The facility's own policy requires immediate reporting of such allegations, but this was not followed in these cases.