Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving one resident to the state licensing agency as required. According to the record review, there was no evidence that a report was submitted after a resident alleged being hit with a wet towel by a staff member. Additionally, there was no documentation of an investigation into the allegation in the resident's medical record. The facility's policy requires immediate reporting and investigation of all alleged violations to the appropriate authorities, including the state agency and adult protective services. Interviews with facility staff revealed that the incident was communicated internally through the EHR and discussed among the hospice nurse, Assistant DON, and former DON. The Administrator and DON were aware of the allegation, but the leadership team decided not to report it to the state agency, citing their belief that the resident was experiencing hallucinations. This decision was made despite the facility's policy, which mandates reporting all allegations of abuse regardless of perceived credibility.