Failure to Immediately Report Alleged Abuse and Notify Authorities
Penalty
Summary
The facility failed to immediately report an allegation of abuse involving two residents with dementia, both of whom were assessed as severely cognitively impaired and unable to give consent. On the evening in question, a Certified Resident Care Assistant (CRCA) discovered one resident in another resident's room, with one resident touching the other's breast and thigh while the latter was not wearing pants. The CRCA separated the residents and informed the on-duty Registered Nurse (RN), but did not escalate the report to the Executive Director (ED) as required by facility policy, citing the ED's unavailability and a history of not answering calls. The RN, upon being informed, contacted the Assistant Director of Health Services (ADHS) but did not notify the ED or the Indiana Department of Health (IDOH). The ADHS, in turn, contacted corporate leadership but did not initiate a formal report to the state or conduct a thorough investigation, as she was not fully informed of the details of the incident, including the fact that one resident was not wearing pants and was being touched inappropriately. The Director of Health Services (DHS) and other members of the interdisciplinary team were also unaware of the full extent of the incident, as the CRCA was not interviewed and her account was not documented in detail. Facility policy required immediate reporting of suspected abuse to the ED and state authorities, but this process was not followed. The incident was not reported to the IDOH as a reportable event, and no internal investigation was initiated to gather statements or clarify the events from all involved staff. The lack of timely and complete reporting, as well as the failure to follow up with the primary witness, resulted in a deficiency related to the facility's abuse reporting procedures.