Failure to Report Alleged Abuse to State Survey Agency
Penalty
Summary
The facility failed to ensure that all alleged abuse violations were reported to the State Survey Agency as required by its own policy. The policy mandates immediate reporting of alleged abuse, neglect, or theft to the administrator and appropriate authorities, including the State Survey Agency, within specified timeframes. However, for three of five reviewed cases involving alleged abuse, the facility did not report the incidents as required. In one instance, a resident with a history of major depressive disorder, anxiety, pain, and cerebral palsy reported that a CNA told her to "shut up" when she complained of leg pain during repositioning. The resident reported the incident to the former administrator, who initiated an internal investigation but did not report the allegation to the State Survey Agency, believing it did not constitute abuse. In another case, a cognitively intact resident with paraplegia reported that two CNAs hurt him during care, including being jerked and slapped with a wet towel. The resident stated that no one followed up with him about his complaint, although the CNAs were removed from his care. A third resident, also cognitively intact and with diagnoses including anxiety, pain, and hemiplegia, reported to the DON that a CNA hurt him during care and spoke to him inappropriately. The DON acknowledged receiving the complaint but considered it a customer service issue and did not report it to the state. In all three cases, the facility failed to follow its policy for reporting alleged abuse to the State Survey Agency, as confirmed by interviews with staff and review of facility records.