Failure to Report Abuse Allegation to Required Agencies
Penalty
Summary
The facility failed to implement its own policy regarding the reporting of an abuse allegation involving a resident with multiple medical conditions, including metabolic encephalopathy, dementia, hemiplegia, and hemiparesis. The resident, who had moderate cognitive impairment, reported an incident where a CNA struck her on the head, causing her head to hit the bed's side rail. This incident was witnessed indirectly by a family member during a phone call and subsequently reported to facility staff. Upon learning of the allegation, facility staff, including the Director of Staff Development (DSD), Infection Preventionist (IP), Director of Nursing (DON), and the Administrator, were informed. The CNA involved was immediately removed from resident care, and an internal investigation was initiated. However, the staff did not report the allegation to any external agencies, such as the Ombudsman, law enforcement, or the state licensing agency, as required by the facility's policy and regulatory guidelines. The facility's policy clearly states that all allegations of abuse must be reported to the appropriate external agencies immediately, defined as within two hours for abuse allegations or those resulting in serious bodily injury. Despite this, the staff acknowledged during interviews that the required external reporting did not occur. The failure to follow the established reporting procedures constituted a deficiency in the facility's abuse prevention and response protocols.