Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an incident of alleged abuse involving a resident with severe cognitive impairment and significant physical care needs. The resident, who had diagnoses including Alzheimer's disease, hypertension, osteoarthritis, and a recent right hip fracture repair, was dependent on staff for multiple activities of daily living. The incident began when the resident's family, monitoring care via a room camera, observed an agency CNA behaving unprofessionally and allegedly mocking the resident during care. The family contacted the facility's Administrator, who, after being informed of the situation and reviewing video evidence, removed the CNA from duty and placed her on a do-not-return list. Further review of the video clips revealed that during care, the CNA mimicked the resident's expressions of pain and was observed handling the resident in a manner that caused the resident to cry out. The CNA was seen pushing and turning the resident, who had a recent hip repair, while the resident expressed pain. An LPN was present during part of the care and was heard asking the resident about pain and referencing recent administration of Tylenol. The CNA continued to provide care despite the resident's distress, and the video captured additional unprofessional conduct, including the CNA pushing the resident's bed with her legs. Despite the evidence and the facility's internal investigation, the incident was not reported to the State Survey Agency as required by both regulation and the facility's own policy on abuse, neglect, misappropriation, and exploitation. The Administrator confirmed during interviews that the incident was not reported, and a review of the state's self-reported incident tracking system showed no record of the event. The facility's failure to report the alleged abuse constituted noncompliance with regulatory requirements.