Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the administrator and to the State Survey Agency as required by policy and regulation. The deficiency involved two residents with severe cognitive impairment, both of whom were involved in incidents where a staff member allegedly used threatening and demeaning language. The facility became aware of these allegations but did not report them to the State Agency within the required timeframe. One resident with vascular dementia reported to a surveyor that staff yelled at her often, which made her feel not good. A Certified Nursing Assistant (CNA) observed another CNA being reckless with residents and overheard the staff member threaten to "beat your butt" to a resident. The CNA reported the incident to a nurse and the Director of Nursing (DON), expressing concern for her own safety and requesting police involvement. The DON sent the alleged perpetrator home and notified the Nursing Home Administrator (NHA), but the incident was not reported to the State Agency. Another resident with Alzheimer's Disease and metabolic encephalopathy was also involved in the incident. The NHA and DON both acknowledged that the incident constituted an allegation of abuse and that it should have been reported to the State Agency within two hours. However, the NHA decided not to report the incident after conducting an internal investigation and determining that witness statements varied and one CNA would not provide a statement. Despite facility policy requiring immediate reporting and investigation, the required notification to the State Agency did not occur.