Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency as required by regulatory guidelines. According to the facility's own Abuse Policy, any reportable incident or allegation must be reported immediately or within 24 hours, with a follow-up investigation submitted within 5 working days. A review of an investigative summary revealed that the Director of Nursing (DON) was notified of an incident involving an LPN and two residents, where the LPN was observed speaking firmly and using a curse word in response to a resident. Staff interviews provided conflicting accounts, with one staff member recalling loud talking and another denying verbal abuse. The DON conducted interviews and documented findings but did not report the allegations to the State Agency, stating that nothing had happened. Further interviews revealed that the DON was aware of the incident and had a personal relationship with the LPN involved, which influenced the handling of disciplinary actions. The DON confirmed that the incident was not reported because they believed no abuse had occurred. The Nursing Home Administrator (NHA) also confirmed that there was no documentation of the investigation and acknowledged that the incident should have been reported to the State Agency. The failure to report the allegation had the potential to affect all residents in the facility.