Failure to Report Resident's Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency for one resident. The resident, a female recently admitted to the facility, used her phone to call 911 and reported to the dispatcher that she was being held against her will, had been assaulted by staff, was not allowed to make phone calls, and implied that she had been sexually assaulted by staff. A CNA discovered the resident on the phone with 911, spoke to the dispatcher, and explained that the resident was confused and the call was a mistake. Despite being aware of the resident's allegations, the CNA did not notify the facility's Abuse Coordinator. Further interviews revealed that another CNA was also aware of the 911 call and the resident's abuse allegations but did not report the incident to the Administrator/Abuse Coordinator, assuming that the nurse would handle it. The Administrator/Abuse Coordinator was not aware of the incident or the police visit until interviewed by surveyors. The facility's policy requires that all allegations of abuse be immediately reported to the Administrator and appropriate state agencies, but this protocol was not followed in this case.