Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the facility administrator and to the State Survey Agency, as well as to law enforcement, as required by both facility policy and state law. In two separate cases, allegations of abuse were not reported to the appropriate authorities. In the first case, a staff member reported that a CNA was yelling at and being rough with a resident. The Nursing Home Administrator (NHA) acknowledged receiving the report and initiating an investigation but did not report the incident to the State Agency or law enforcement. Documentation of the investigation was incomplete, consisting only of three unsigned, undated handwritten interviews, with no additional interviews from other staff or residents. In the second case, a family member raised concerns about the manner in which staff transferred a resident using an EZ stand, describing the staff's approach as abrupt and inappropriate. The family member reported that staff made negative comments about the resident, such as calling her non-compliant and unmotivated, and told her she could remain in her chair or fall on the floor. The resident became emotional, tearful, and confused as a result. The incident was reported to the facility's social worker and documented as a grievance. Both the social worker and the NHA acknowledged that the incident constituted an allegation of abuse and that it should have been reported to the State Agency within two hours, but no such report was made to the State Agency or law enforcement. The residents involved included one with diagnoses of atrial fibrillation and hypertension, who was newly admitted and unfamiliar with the EZ stand transfer device. The failure to report these allegations of abuse as required by policy and regulation represents a deficiency in the facility's abuse reporting procedures. The events were substantiated through interviews with staff, the NHA, the social worker, and the family member, as well as review of grievance documentation.