Failure to Immediately Report Alleged Abuse as Required by Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented and followed its abuse policy requiring immediate reporting of alleged abuse to administration. The facility’s abuse policy, revised March 2023, stated that alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown origin and misappropriation of resident property, must be reported immediately to the administrator and DON using the chain of command, with a two-hour requirement to report allegations to the Department of Public Health and local law enforcement. Resident #1, admitted in December 2025 with dementia and generalized muscle weakness, had a comprehensive MDS dated 12/10/25 indicating severe cognitive impairment and dependence on staff for care needs. On 12/13/25, Nurse #1 heard a family member yelling and swearing at CNA #1, accusing him of abusing the resident and causing bruises on the resident’s arms. Nurse #1 stated she stepped away from the situation because of the yelling and did not want to be involved, and there was no documentation that she notified her supervisor or administrative staff of the altercation or the abuse allegation at that time. The next day, the weekend Nursing Supervisor reported that the family member initially complained that CNA #1 had not properly cleaned the resident, and later told her that she believed CNA #1 was responsible for bruises on the resident’s arms and wanted to speak with him. The Nursing Supervisor did not immediately contact the administrator or DON as required by policy, but instead placed a written statement under the administrator’s door that day. The DON stated that facility policy requires all staff to immediately report any suspicion or allegation of abuse to their supervisor or administration and confirmed that the weekend Nursing Supervisor, who was aware of the allegation on 12/14/25, did not immediately report it to her or the administrator. The administrator reported that he was not made aware of the allegation of staff abuse involving the resident until 12/15/25, when police arrived and informed him that the resident’s family had reported rough handling by CNA #1 that allegedly caused bruising on the resident’s arm. This sequence of events shows that staff who became aware of the allegation on 12/13/25 and 12/14/25 did not follow the facility’s abuse reporting policy.
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