Failure to Timely Report and Investigate Alleged Resident Abuse
Penalty
Summary
The facility failed to report allegations of abuse involving five residents within the required 24-hour timeframe to local law enforcement, Adult Protective Services (APS), and the Long-Term Care Ombudsman. The facility's own policies require immediate reporting and investigation of suspected abuse, neglect, or exploitation, but these procedures were not followed. The initial incident occurred when a CNA was observed by another CNA to handle residents roughly and speak to them in a harsh tone. The witnessing CNA did not report the incidents until two days later, delaying the initiation of an investigation and the required notifications to authorities. Multiple staff interviews confirmed that abusive behavior by the CNA had been witnessed on several occasions, including physical roughness, belittling, and slapping a resident. Some staff admitted to witnessing or being aware of the CNA's behavior but failed to report it to the DON, ADON, or Administrator as required. The DON, ADON, and Administrator all acknowledged that the incidents should have been reported immediately and that the delay in reporting and investigation was not in accordance with facility policy or regulatory requirements. The residents involved had significant cognitive and physical impairments, including dementia, Alzheimer's disease, muscle weakness, and incontinence, making them dependent on staff for all activities of daily living. The failure to promptly report and investigate the allegations of abuse left these vulnerable residents without timely protection or intervention. The facility did not notify the appropriate external agencies as required, and the deficiency was confirmed through policy review, medical record review, and staff interviews.