Failure to Timely Report and Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that an allegation of employee-to-resident physical abuse was reported to the state agency as required. A resident alleged that a Licensed Nurse twisted his arm and took away his cat food, an incident reportedly witnessed by a CNA. The resident stated he informed the DON about being physically hurt and also called the police to make a report. Despite the resident's statements and the police being involved, the facility did not report the allegation to the state agency or other required authorities. Interviews and record reviews revealed that the DON was aware of the abuse allegation but did not report it, citing information from a police officer that the resident had recanted the story. However, review of the police report showed no evidence that the resident recanted, and the DON did not confirm this with the resident or document it in the medical record. The DON also did not interview other potential witnesses, such as the resident's roommate, nor did the facility conduct its own investigation or complete the required notifications per facility policy. Facility policy required immediate investigation and reporting of all alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified time frames. The Administrator confirmed that the expectation was for all staff to report allegations immediately and make all required notifications within two hours. The failure to follow these procedures resulted in a delayed abuse investigation and a lack of required notifications.