Failure to Report Alleged Staff-to-Resident Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of staff-to-resident physical and verbal abuse to the State Agency as required. The incident involved a resident with diagnoses of dementia and major depressive disorder, who was severely cognitively impaired and required behavioral monitoring. During a lunch service, a dietary manager observed a CNA become aggressive with the resident after the resident scratched the CNA's hand while both reached for a drink. The CNA reportedly grabbed the resident's wrists and loudly told the resident not to scratch her. The dietary manager reported the incident to the DON and later inquired if her written statement was needed, but was told by the Administrator that it was not necessary. The Administrator, who was ill at the time of the incident, indicated that he did not believe the event was reportable and did not submit a report to the State Agency. He conducted an internal investigation, which included interviews with the involved CNA and other staff, but found no evidence to substantiate the allegation. The Administrator also noted interpersonal conflicts between the dietary manager and the CNA, which influenced his perception of the credibility of the report. The DON confirmed that she had notified the Administrator of the allegation and that no written statements were collected from the witnesses at the time. Facility policy required that all allegations or suspicions of abuse be immediately reported to the Administrator and the State Agency, and that written statements from witnesses be collected within 24 hours. Despite these requirements, the facility did not report the incident to the State Agency, did not collect written statements from all involved parties, and did not document the incident in accordance with policy. The failure to report the allegation and follow established procedures resulted in noncompliance with regulatory requirements for abuse reporting.