Failure to Report Alleged Abuse and Neglect to Authorities
Penalty
Summary
The facility failed to ensure that allegations of potential verbal and physical abuse involving three residents were reported to the Nursing Home Administrator (NHA) or designee and to law enforcement as required by facility policy and regulation. In one instance, a resident complained that a Certified Nursing Assistant (CNA) was rough during care, including pulling the resident's legs apart and being rough while cleaning, which caused the resident to express pain and distress. Although the incident was reported internally and the CNA was removed pending investigation, law enforcement was not contacted, contrary to policy requirements for reporting suspected abuse. In two additional cases, a Registered Nurse (RN) was alleged to have verbally and physically abused two residents on the same night. One resident, who had severe cognitive impairment and was dependent for care, was reportedly rolled aggressively and wiped in a manner described as aggressive, with the RN making an inappropriate statement to the resident. The incident was not immediately reported to the NHA, and law enforcement was not notified. The second resident, who had hemiplegia, hemiparesis, and dementia, was also allegedly rolled and wiped aggressively by the same RN, causing visible signs of pain. This allegation was not reported to the state agency or law enforcement, and there was no documented investigation for this resident. Staff interviews and record reviews revealed that statements regarding these incidents were left under the Director of Nursing's (DON) office door while the DON was absent, and there was confusion among staff about reporting procedures. The NHA and Director of Social Services only became aware of the incidents after being informed by another CNA during an unrelated meeting. The facility's failure to report these allegations to the appropriate authorities within the required timeframes constitutes a deficiency in following abuse reporting protocols.