Failure to Timely Report Alleged Resident Abuse
Penalty
Summary
A deficiency occurred when the facility failed to timely report an allegation of abuse involving a resident with diagnoses including hemiplegia, cerebral infarction, right hip fracture history, seizure disorder, and hypertension. The resident, who had intact cognition and required moderate staff assistance, reported to two CNAs that a staff member had intentionally turned cold water on him during a shower as a form of mistreatment. The CNAs, after being informed of the allegation, attempted to communicate the incident to their supervisor, the Coach Manager (CM), but the CM did not follow up or report the allegation to the Administrator as required by facility policy. The incident was not reported to the Administrator until it was brought to attention by a surveyor during the annual survey, despite multiple opportunities for staff and the CM to escalate the allegation. Interviews confirmed that neither the CNAs nor the CM reported the abuse allegation to the Administrator or other management in a timely manner, contrary to the facility's policy that mandates immediate reporting of all abuse allegations. The Administrator verified that she was unaware of the incident until the surveyor's inquiry and emphasized that immediate reporting to her or a supervisor is required.