Failure to Timely Report Alleged Abuse by Staff
Penalty
Summary
The facility failed to identify and timely report an allegation of potential abuse involving a resident with complex medical needs who was cognitively intact and required assistance with activities of daily living. Staff observed and became aware of suspicious interactions between a staff member and the resident, including being found together behind locked doors in the therapy gym when it was closed and unscheduled for therapy. Despite these observations and suspicions, staff did not immediately report the concerns to facility leadership as required by policy. Instead, one staff member confronted the staff involved and discussed the situation with other staff, while others who heard about the suspicions did not report them because they had not personally witnessed inappropriate behavior. The delay in reporting resulted in the administrator being notified of the concern eight days after the initial suspicion was identified. Interviews confirmed that multiple staff members were aware of the situation or had been told about it but failed to report the suspicion of abuse in a timely manner, as required by facility policy and state regulations. The failure to promptly report the allegation placed residents at risk and did not ensure immediate intervention or investigation.