Failure to Report Staff-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the State Survey Agency, as required by policy. Medical record review showed that a resident with a history of cerebrovascular attack and depression, who was dependent on staff for mobility and communication, was involved in an incident where a CNA responded inappropriately to the resident's call light, delayed care, and made unprofessional and threatening remarks. The CNA also left the resident exposed and unattended, handled the resident roughly during a transfer, and placed the resident back into a dirty bed. Witness statements from another resident corroborated the events, including the CNA's use of her cell phone during care and her verbal threats toward the resident. Despite the seriousness of the allegations, the facility's Self-Reported Incidents (SRI) log did not include this incident, and the Administrator confirmed that the abuse allegation was not reported to the Ohio Department of Health. The Administrator stated he was unaware of the abuse aspect of the incident until several days later and acknowledged that the required report was not filed. Facility policy mandates immediate reporting of all abuse allegations to the Administrator, DON, and the State Agency, but this protocol was not followed in this case.