Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the administrator and to the State Survey Agency as required by state and federal regulations. In five separate cases, allegations of abuse or neglect were either not reported at all or not reported in a timely manner. These included incidents involving unwanted touching by a staff member, verbal and mental abuse, rough handling during care, and refusal to provide care. In each case, the facility's own policy required immediate reporting to the state agency, but this was not followed. One resident with mild cognitive impairment, anxiety, and depression reported that a nurse threw a pill in her mouth and made a derogatory comment, and later reported that a CNA caused a bruise by being rough during care. Both incidents were documented as concerns but were not reported to the state agency as allegations of abuse. Another resident and her representative reported unwanted touching in the vaginal area by an LPN during a skin assessment, which made the resident uncomfortable and fearful. Despite the resident's request for a female caregiver and the clear policy on reporting such allegations, the incident was not reported to the state agency or law enforcement. Additional incidents included a CNA reporting that an RN yelled at a resident, pulled a blanket off without warning, and slammed doors, which was not reported as verbal or mental abuse. Another resident's representative reported that a staff member refused to assist with care, and a resident reported being handled roughly during evening care. In all these cases, staff and management acknowledged during interviews that these were allegations of abuse or neglect that should have been reported, but there was no evidence that the required reports were made to the state agency.