Failure to Report Alleged Mental Abuse as Required by Policy
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, specifically regarding mental abuse, for one resident. The resident filed a grievance alleging that a nurse mocked her, refused to provide medication promptly, and made a gesture indicating she was 'crazy' in front of her and a family member. The resident described feeling angry, disgusted, and disrespected by the nurse's actions, which she considered unprofessional and undignified. Despite these allegations, there was no evidence that the incident was reported to state agencies as required by facility policy and federal regulations. Record review showed that the resident was cognitively intact, with a BIMS score of 15, and had multiple chronic medical conditions, including atrial fibrillation, COPD, diabetes, and anxiety. The resident's progress notes did not indicate any changes in mood or behavior following the incident, and there were no care plans addressing behavioral issues or confabulation, contrary to statements made by facility leadership. The facility's report tracking log confirmed that no abuse, neglect, or exploitation allegations were reported for this resident during the relevant period. Interviews with facility staff, including the Risk Manager and DON, revealed a lack of clarity regarding what constitutes a reportable event. The Risk Manager acknowledged upon review that the incident should have been reported but was instead treated as a customer service issue rather than potential mental abuse. The facility's policy clearly defines mental abuse and outlines mandatory reporting requirements, which were not followed in this case.