Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with moderate cognitive impairment and a history of behavioral disturbances. The resident, who had diagnoses including dementia with agitation, major depressive disorder, and Alzheimer's disease, exhibited behaviors such as yelling, making accusations against staff, and threatening self-harm. On multiple occasions, the resident accused staff of physical abuse, including being hit and kicked by a nurse, and these allegations were witnessed and reported by certified nursing assistants and a registered nurse. Witness statements indicated that staff heard noises consistent with a possible physical altercation and observed the resident in distress immediately after interactions with the accused staff member. Despite these allegations and witness observations, the facility did not submit a Self-Reported Incident (SRI) to the state survey agency as required by their policy. The policy mandates immediate reporting of abuse allegations involving employees, but a review of the Certification and Licensure System showed no evidence of such a report being filed for this incident. Interviews with staff and administration confirmed that the incident was communicated internally, but the administrator decided not to report the allegation to the state due to the resident's history of making similar accusations. The facility's failure to report the abuse allegation was in direct violation of its own policy, which requires prompt notification of the state agency for any employee-related abuse allegations. The administrator acknowledged receiving the report from nursing staff but did not follow through with the mandated external reporting process. This omission was identified during a review of medical records, staff interviews, and facility documentation.