Failure to Notify Physician and Family of Abuse Allegation
Penalty
Summary
The facility failed to notify a resident’s physician and family of an allegation of abuse involving that resident. A resident with moderate cognitive impairment, as evidenced by a BIMS score of 12 on the 12/28/25 MDS and diagnoses including Alzheimer’s disease, non-Alzheimer’s dementia, anxiety, and depression, was the subject of an internal Complaint Investigation dated 1/6/26. In that investigation, two CNAs (Staff A and Staff B) reported to the Administrator that another CNA (Staff C) told them she slapped the resident after the resident put his hands down her sweater, and that she told him to keep his “f***ing hands” off her. Review of the clinical record showed no documentation that this allegation of abuse was reported to the resident’s physician or family. The DON confirmed the family had not been called about the allegation, and the Administrator confirmed the physician had not been notified, despite facility policy requiring proper notification to the primary care provider and responsible party for allegations of resident abuse. The facility’s Abuse Prevention, Identification, Investigation and Reporting Policy, revised 9/29/21, stated that the Administrator would complete documentation of the allegation of resident abuse and collect supporting documents related to the alleged incident, including providing proper notification to the primary care provider and responsible party. In this case, the required notifications were not made following the reported allegation that a staff member slapped the resident and used profane language, and this omission was verified through record review and staff interviews.
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