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F0609
D

Failure to Timely Report Alleged Abuse to Proper Authorities

Milwaukee, Wisconsin Survey Completed on 07-28-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when staff failed to report an allegation of inappropriate touching between residents in a timely manner, as required by facility policy. A resident with intact cognition reported to a physical therapist that another resident had put a hand inside their shorts during lunch. The physical therapist documented the incident on a Stop and Watch form and notified the unit nurse. However, the nurse did not escalate the report to the Nursing Home Administrator (NHA) or other appropriate authorities, instead speaking with the resident and concluding that no further action was needed after the resident denied the incident. This resulted in a delay of at least twelve hours before the NHA was notified and the incident was reported to the state agency. Facility policy required immediate reporting of abuse allegations, but staff failed to follow this protocol. The NHA and Director of Clinical Services confirmed that the Stop and Watch form was not the appropriate method for reporting abuse and that the nurse should have reported the incident immediately. The delay in reporting was attributed to the nurse's decision not to escalate the matter, despite being made aware of the allegation by the physical therapist.

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