Failure to Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an alleged incident of abuse involving one resident, as required by their policy and regulatory guidelines. According to a hospital discharge plan, the resident reported to hospital staff that facility staff had subjected her to waterboarding for 36 hours, thrown her on the floor, and forced her to endure weekly hour-long cold showers, including having water poured on her face and in her ear. Additionally, the resident reported to surveyors that she had informed unidentified staff that she could not tolerate being in the facility any longer, and that staff had verbally abused her by calling her derogatory names and making statements suggesting she should die. Despite receiving this information from the hospital, the DON, Corporate Nurse, and Administrator acknowledged during interviews that the incident was not reported to the appropriate agencies as required. Review of the facility's abuse policy confirmed that all alleged violations must be reported immediately, but not later than two hours after the allegation is made, particularly if the events involve abuse or result in serious bodily injury. The failure to report these allegations was confirmed through record review and staff interviews, and the incident involved one of six residents reviewed in a facility with a census of 107.