Failure to Timely Report Abuse Allegation to Licensing Board
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of abuse and mistreatment to the appropriate licensing board for five out of six sampled residents. According to the facility's policy, mechanisms should be in place for reporting, investigating, and monitoring abuse, neglect, and misappropriation of property. An initial incident report documented that a CNA was alleged to have physically and emotionally abused multiple residents, including rolling them roughly into walls and slamming a food tray in front of a resident. The initial report did not indicate that the nurse aide registry was notified of the abuse allegation at the time the incident was reported to the state agency. The residents involved had varying degrees of cognitive impairment and medical conditions, including severe obesity, hearing loss, dementia, anxiety disorder, and hemiplegia. Despite the serious nature of the allegations and the facility's policy requirements, the notification to the nurse aide registry was delayed and only documented in a final incident report two days after the initial report. The administrator confirmed that the nurse aide registry should have been notified when the initial incident was reported.