Failure to Report Alleged Physical Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of employee-to-resident physical abuse to the State Survey Agency, the ombudsman, and local law enforcement as required by its own policy. The incident involved an activities assistant alleging that a certified nursing assistant pushed a resident in a wheelchair, which was considered a potential act of abuse. Despite the allegation, the administrator did not report the incident, citing that the resident had no injuries and that the information was considered hearsay rather than a direct report. The resident involved had significant cognitive and physical impairments, including dementia, Alzheimer's disease, muscle weakness, and a high risk for falls. The resident was dependent on staff for most activities of daily living and did not have the capacity to make decisions. On the day of the incident, the resident was found on the floor after being left in the dining room by the CNA, and there were conflicting accounts from staff regarding how the resident ended up on the floor. The administrator reviewed CCTV footage but did not preserve it, as it was automatically erased after five days. Interviews with staff revealed that the term "push" was used by the activities assistant, leading to the CNA's suspension and eventual termination. The administrator acknowledged that any allegation of abuse, including those based on staff statements or hearsay, should be reported within two hours according to facility policy. However, the administrator did not report the incident, stating it was not directly reported to her and was considered hearsay, despite recognizing that the use of the word "push" raised concerns for abuse.