Failure to Timely Report Alleged Abuse to Administrator and State Authorities
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. Specifically, a staff member witnessed an incident involving potential sexual misconduct by a CNA toward a resident but did not report the incident at the time it occurred. The staff member later communicated the event to another CNA, who then relayed the information to additional staff, resulting in a delay of approximately two to three weeks before the allegation was formally reported to facility leadership. The resident involved had diagnoses including severe anemia, major depressive disorder, and anxiety disorder, and was assessed as cognitively intact. The incident in question was described as the CNA performing a repetitive motion in the resident's genital area under a towel, which was observed by another CNA. The observing CNA did not immediately report the incident due to personal trauma and uncertainty about the reporting process, only coming forward after discussing the event with another staff member. Upon learning of the allegation, the facility removed the accused CNA from the schedule and began an internal investigation. However, the delay in reporting meant that the administrator and state authorities were not notified within the required timeframe. Interviews with facility leadership confirmed that the expectation was for such allegations to be reported to the state within two hours of discovery, which did not occur in this case.