Failure to Report Resident Mistreatment to State Agency
Penalty
Summary
The facility failed to report an allegation of resident mistreatment to the State Agency as required by policy. A resident with dementia, depression, and psychosis, who was cognitively intact, reported being verbally targeted by a CNA who made repeated comments about the President coming to get her, knowing this was a source of fear and anxiety for the resident. The incident resulted in the resident experiencing significant distress, including staying awake all night and remaining in the common area due to fear, as confirmed by staff witness statements. Documentation revealed that the CNA received disciplinary action for intimidating a resident, but there was no evidence in the resident's medical record or facility self-reported incidents log that the event was reported to the State Agency. Staff interviews confirmed awareness of the incident and its impact on the resident, with one nurse stating that the situation was reported internally due to the resident's heightened anxiety. However, the Director of Nursing acknowledged that no self-reported incident was initiated or submitted to the State Agency, citing a lack of awareness of the reporting requirement. The facility's policy required immediate reporting of all allegations of abuse, mistreatment, neglect, or exploitation to both the administrator and the State Agency. Despite this, the incident involving the resident and the CNA was not documented in the progress notes nor reported externally, constituting a failure to follow established procedures for reporting suspected mistreatment.