Failure to Timely Report Alleged Abuse and Improper Restraint
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment—including injuries of unknown source—were reported immediately to the administrator and appropriate authorities as required. Multiple staff members observed or were informed of incidents involving a resident with severe cognitive impairment, hemiplegia, and a history of falls, but did not report these allegations in a timely manner or to the correct individuals. Specifically, a CNA witnessed another CNA yanking the resident out of bed and threatening to kill him in Spanish, but did not report this to the administrator and delayed reporting to other supervisors. Another CNA observed the resident's wheelchair wheels tied together with plastic bags, restricting mobility, but did not escalate the incident to the DON or administrator, relying instead on the assumption that another nurse had reported it. Further, the DON and UM were notified by an LVN that the resident had been restrained with trash bags on his wheelchair, but neither reported the allegation to the administrator as required by facility policy and federal regulations. Interviews revealed confusion and lack of clarity among staff regarding reporting protocols, with some staff unsure of who the administrator was or how to contact them. Documentation confirmed that staff had received training on abuse prevention and reporting, and had signed policies outlining their responsibilities, yet failed to act according to these protocols when faced with actual incidents. The resident involved was highly vulnerable due to severe cognitive impairment, hemiplegia, and a high risk of falls, requiring substantial assistance for daily activities. Despite this, staff failed to report and escalate serious allegations of abuse and improper restraint, including physical handling and threats, as well as the use of makeshift restraints that restricted the resident's primary mode of mobility. These failures resulted in a lack of timely investigation and notification to state authorities, as required by both facility policy and federal regulations.