Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with diagnoses including epilepsy, dementia with agitation, anxiety disorder, and cognitive communication deficit. The resident reported to a police officer at the hospital that she had been assaulted within the last two weeks at the facility, stating someone placed their hands on her wrists causing injury while she was in her wheelchair. The officer did not observe visible injuries, and the resident could not identify the alleged perpetrator. The police officer followed up at the facility and spoke with the resident's case worker, who was unaware of any assault incidents and had no documentation of such events in the resident's record. The case worker recalled discussing the police visit with the DON, but the DON stated she was only informed about concerns related to money and was unaware of any abuse allegation. The DON confirmed that, had she known, she would have filed a self-reported incident and initiated an investigation. Facility policy requires immediate reporting of all alleged violations involving abuse, neglect, exploitation, or mistreatment, but this process was not followed in this case. The deficiency was identified through record review, police report review, interviews, and policy review.