Failure to Timely Report Alleged Abuse by Visitor
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than two hours after the allegation was made, as required by regulation and facility policy. Specifically, a visitor was observed by a CNA pounding hard on a resident's bed and yelling, "Wake up!" The resident's roommate questioned the visitor's behavior, asking why they were always so mean. The CNA reported the incident to an LVN, who then reported it to the ADON, but neither the administrator nor the state agency was notified within the required timeframe. The administrator only became aware of the incident after being informed by the surveyor and confirmed that she had not seen the relevant nursing note prior to this intervention. The resident involved was an elderly female with Alzheimer's disease, severe cognitive impairment (BIMS score of 01), and significant functional dependencies, making her particularly vulnerable. Record review confirmed that no self-reported incidents regarding allegations of neglect or abuse were submitted to the state system. Interviews with staff revealed a misunderstanding of the reporting chain of command, with both the CNA and LVN believing that their actions fulfilled reporting requirements, while the ADON did not recall receiving a report. Facility policy required prompt reporting of suspected abuse, including by visitors, but this was not followed in this case.