Failure to Report Allegations of Abuse to State Agency
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency for two residents, despite being aware of the incidents. One resident, who had Huntington’s Disease and moderate cognitive impairment, reported that a staff member was rude to her and also described a verbal altercation with a roommate, expressing that she did not feel safe. These concerns were documented in facility grievance forms, and immediate actions such as moving the roommate were taken. However, the Nursing Home Administrator, who served as the abuse coordinator, determined that these incidents did not meet the criteria for abuse and did not report them to the state. Documentation provided for these events was minimal, with no thorough investigation records available beyond brief notes indicating the incidents were considered non-reportable and that no harm or distress was observed. Another resident reported waiting two hours for assistance and described being handled roughly by a staff member, which caused her pain. This concern was documented in a grievance form and a non-reportable allegation form, with a nursing assessment performed that found no new information or injury. The administrator and DON interviewed the resident, who stated she was in pain but could not identify the staff member involved. The administrator concluded that the incident was related to the resident’s underlying pain rather than staff mistreatment, and therefore did not report the allegation to the state agency. In both cases, the facility’s actions were limited to internal documentation and brief follow-up, without conducting or documenting thorough investigations or reporting the allegations to the appropriate authorities as required. The decision not to report was based on the administrator’s judgment that the incidents did not meet the threshold for abuse, despite the residents’ statements and the facility’s own documentation of their concerns.