Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that allegations of abuse were reported to the State Agency (SA) for one resident who was admitted for a 5-day respite stay and had a diagnosis of Alzheimer's disease, among other conditions. On the evening in question, the resident became agitated and attempted to leave the facility through multiple doors. Staff responded by holding the doors shut and physically restraining the resident to prevent elopement, including holding the resident in a chair. Law enforcement was called to assist, and a police report documented that the resident alleged being attacked by numerous individuals. The police also observed staff who appeared distressed and noted that staff were holding the resident in a chair upon arrival. Despite these events and the facility's own policy requiring immediate reporting of suspected abuse to the SA, the Nursing Home Administrator (NHA) did not report the incident, citing the absence of resident injuries and attributing the situation to behavioral issues. The NHA also did not conduct interviews with staff involved in the incident and relied solely on statements obtained by law enforcement. Additionally, the NHA had not reviewed all relevant documentation, including the police and crisis reports that contained allegations of abuse. The failure to report the incident to the SA constituted a deficiency in the facility's abuse reporting procedures.