Failure to Report Alleged Abuse to State Agency and Law Enforcement
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the State Survey Agency and law enforcement as required by policy. Specifically, a resident with a history of bipolar disorder, antisocial personality disorder, kidney disease, and diabetes, who was moderately cognitively impaired, reported to hospital staff that a nurse at the facility had thrown him onto his bed. This allegation was communicated to the facility's Nursing Home Administrator (NHA) by a hospital care coordinator. The NHA acknowledged receiving the report and stated she would follow up. Upon receiving the allegation, the NHA spoke with the nurse and CNA who were present during the incident, and their statements matched. The NHA also spoke with the resident, who expressed no current concerns, felt safe, and could not recall the incident. Despite recognizing that the resident's statement could be considered an allegation of abuse and should be investigated and reported, the NHA did not report the incident to the state agency or law enforcement. This omission was identified during a review of five investigations, with this case being the only one where the required reporting did not occur.