Failure to Timely Report Allegations of Abuse to State Survey Agency
Penalty
Summary
The facility failed to report multiple allegations of abuse to the State Survey Agency (SSA) as required by both facility policy and federal regulations. In the case of one resident with moderate cognitive impairment and a history of dementia, the resident alleged that a registered nurse shoved a bedside table into their knee and spilled water on them. Multiple staff members, including two CNAs and the RN involved, became aware of the allegation and reported it to the Interim Director of Nursing (IDON). However, the IDON did not report the incident to the SSA, stating she did not believe the CNA and did not consider the behavior to be abuse. The Administrator was not made aware of the full details of the incident and confirmed that the allegation should have been reported to the SSA within two hours, as per facility policy. Another incident involved a resident with intact cognition who reported that a CNA told them to "shut up" and was rude. This allegation was reported to the Administrator, but there was no evidence that it was reported to the SSA. The Social Services Director confirmed that such language constituted verbal abuse, and both the IDON and Administrator acknowledged that the incident should have been reported to the SSA. The Administrator admitted to forgetting to document and report the allegation. A third incident involved a resident with a history of mental health diagnoses who was discharged after allegedly making a death threat to another resident and possessing weapons and pills in their room. The discharge notice cited the threat and the presence of weapons as reasons for the emergency discharge, but there was no evidence that the threat was reported to the SSA. Staff interviews confirmed that the threat and the presence of weapons were known to facility leadership, and the Administrator acknowledged that the incident should have been reported. Facility policy required immediate reporting of all alleged violations to the SSA, but this was not followed in these cases.