Failure to Report Alleged Staff-to-Resident Abuse to State Agency and Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of staff-to-resident physical and verbal abuse to the state survey agency (DIAL) and to law enforcement as required by facility policy and federal regulations. On 1/6/25 at approximately 4:15 PM, Staff A and Staff B, both CNAs, reported to the Administrator that Staff C, CNA, had told them she slapped Resident #1 after he put his hands down her sweater and that she told him to keep his “fucking” hands off her. Staff A stated that Staff C reported the incident occurred on Christmas while she was wearing an “ugly grinch” sweater and that Resident #1 reached down her shirt and grabbed her breast, at which point she smacked him across the face. Staff B similarly reported that Staff C told her she had been wearing a lighted Christmas sweater when the resident reached down her shirt, grabbed her “boob,” and she slapped him across the face, using profanity to describe the event. Staff A further reported that when she informed Staff D, an RN and mandatory reporter, Staff D responded that she would have “throat punched” the resident. The facility’s Complaint Investigation form dated 1/6/26 documented that Staff A and Staff B reported this allegation of abuse to the Administrator. Review of the facility’s Self Report List from January 2025 to January 2026 showed the facility did not file this abuse allegation with DIAL. The facility’s Abuse Prevention, Identification, Investigation and Reporting Policy, revised 9/29/21, required that all allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation be reported immediately to the charge nurse, who must immediately notify the Administrator or designee, and that all allegations of resident abuse be reported to DIAL no later than two hours after the allegation was made. The policy also required reporting to law enforcement under the Elder Justice Act time frames, depending on whether serious bodily injury occurred. Despite these requirements, the Administrator stated on 1/26/26 that she did not file a report to DIAL because she did not believe there was a potential for abuse and later confirmed on 1/27/26 that she did not notify the police of the allegation. No information was provided in the report regarding Resident #1’s medical history or condition at the time of the incident.
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