Failure to Timely Report Allegation of Abuse to Administration and State Agency
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an allegation of abuse was immediately reported to administration so it could be reported to the state survey agency within the required timeframe. Facility policy, revised March 2023, required that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown origin, misappropriation of resident property, and exploitation, be reported immediately to the administrator and DON using the chain of command, and that all abuse allegations require immediate action with notification to the Department of Public Health and local law enforcement no later than two hours after an abuse allegation is received. The resident involved had dementia, generalized muscle weakness, severe cognitive impairment, and was dependent on staff to meet care needs, as documented in a comprehensive MDS assessment dated 12/10/25. On 12/13/25, a nurse heard the resident’s family member yelling and swearing at a CNA, accusing the CNA of abusing the resident and causing bruises on the resident’s arms. The nurse stated she stepped away because the family member was yelling and she did not want to be involved, and she did not take any action or notify a supervisor or administration; there was no documentation that she reported the allegation. The nursing supervisor reported that on 12/13/25 the family member only complained that the CNA had not properly cleaned the resident, and that it was not until the next day that the family member linked the CNA to bruises on the resident’s arms; the supervisor also did not immediately notify administration. The administrator and DON both stated that staff are expected to report any suspicion or allegation of abuse immediately so that administration can report to DPH and police within two hours. However, the administrator did not become aware of the allegation until 12/15/25 when police arrived with the family and reported the allegation of rough care and bruising, and the HCFRS report was submitted that same day, resulting in the allegation being reported to the state agency two days after staff were first made aware of the abuse allegation.
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