Failure to Report Allegations of Abuse to State Survey Agency
Penalty
Summary
The facility failed to ensure that allegations of abuse, specifically resident-to-resident incidents, were reported to the State Survey Agency (SSA) as required by both regulation and facility policy. In one instance, a resident with dementia and behavioral disturbances was reportedly exposed to another resident who approached their room with their pants down. The incident was witnessed by the resident's representative, who intervened and reported the event to nursing staff and later to facility management. Despite multiple discussions with staff, including the Administrator, DON, and Social Services Designee, the incident was not documented as an allegation of abuse nor reported to the SSA. In a separate event, a resident with severe cognitive impairment was found by staff being struck by their roommate with a plastic cup. The incident was observed by an LPN, who notified the charge nurse and DON. The event was discussed in interdisciplinary team meetings, and behavioral interventions were implemented, but the incident was not reported to the SSA as required. Interviews with staff confirmed that such incidents should be reported within two hours, but the Administrator made the final decision not to report these events. Review of facility policy confirmed that all allegations of abuse, neglect, or misappropriation of property were to be reported to the SSA. The failure to report these incidents, despite clear evidence and staff awareness, constituted noncompliance with regulatory requirements and facility policy. The deficiency was identified through medical record review, staff and resident representative interviews, and facility document review.