Failure to Timely Report Alleged Physical Abuse Incidents
Penalty
Summary
The facility failed to report alleged violations of physical abuse within the required timeframe to the Iowa Department of Inspections, Appeals and Licensing (DIAL) for three out of four reviewed incidents. Clinical record review, facility records, policy review, and interviews revealed that incidents involving aggressive and physically abusive behaviors by a resident toward other residents and staff were not reported as mandated. The incidents occurred on multiple dates and included physical altercations such as hitting, striking, and other aggressive behaviors. One resident, with a history of mental illness including depression, anxiety, PTSD, and bipolar disorder, exhibited frequent physical and verbal aggression toward staff and peers. The resident's care plan identified these behaviors and included interventions for staff to manage and document such incidents. Despite these interventions, the care plan lacked specific direction for reporting resident-to-resident altercations and for implementing interventions to prevent further incidents after they occurred. Documentation showed that staff were aware of the reporting requirements and had received training on dependent adult abuse. However, the facility's self-reported incident list showed that only one of the four incidents was reported to DIAL, with the remaining three not reported as required. Interviews with staff and facility leadership confirmed that these incidents should have been reported, and facility policy required prompt reporting of such events to state authorities.