Failure to Timely Report Alleged Physical Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of physical abuse made by a resident was timely reported to the State Survey Agency, as required by policy. The resident, who had diagnoses including type two diabetes mellitus, muscle wasting and atrophy, anxiety, mood disorder, and dementia, was cognitively intact and dependent on staff for bathing and toileting. The resident alleged that two staff members assaulted her in the shower, including placing a water nozzle in her mouth, smothering her with towels, and knocking out her teeth. The incident was reported to a friend, who contacted the police, resulting in law enforcement visiting the facility. Despite these events, there was no Self-Reported Incident (SRI) submitted to the State Survey Agency regarding the allegation. Interviews with facility staff and review of records confirmed that management was aware of the allegation and that a limited internal investigation was conducted, including staff interviews and assessments of the resident's skin and dental condition. However, a full investigation was not completed, and the required formal reporting to the State Survey Agency did not occur. The facility's policy mandates immediate reporting of all allegations of abuse, especially those involving serious bodily injury, but this protocol was not followed in this case.