Failure to Timely Report and Investigate Allegation of Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of physical abuse to the state survey agency within the required two-hour timeframe and to conduct an appropriate investigation. Facility policy stated that all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of resident property must be reported immediately, and no later than two hours, when abuse or serious bodily injury is alleged. Despite this, the Administrator acknowledged that an allegation that a staff member squeezed a resident’s face and told the resident to shut up was not reported to the state agency, and no investigation was completed because the resident later denied the allegation when interviewed in the presence of the accused staff member. The resident involved had a quarterly MDS dated 1/6/26 showing that the resident was cognitively intact (BIMS score of 13), able to make self-understood and understand others, and dependent on staff for ADLs, with diagnoses including hemiparesis, respiratory failure, and traumatic spinal cord dysfunction. The resident’s care plans documented behavioral issues, including becoming easily angered, yelling at staff and family, and pushing against staff while demanding unsafe repositioning methods. Interventions included redirection, involvement of family, and reminders about safe repositioning techniques. These documented behaviors formed part of the context in which the alleged abuse occurred but did not negate the requirement to treat the report as an abuse allegation. Multiple staff interviews established that on or about Friday, January 9th, the resident told a CNA and the Activity Director that a staff member the resident called “Firehead” had squeezed the resident’s cheeks and told the resident to shut up while the resident was yelling and felt like falling out of bed. The CNA and Activity Director reported this as potential abuse to the DON and Administrator. The DON and ADON then interviewed the resident, who reported that a CNA had come into the room, told the resident to be quiet, and squeezed the resident’s cheeks, and the Administrator walked the suspected CNA past the resident’s door, where the resident identified the CNA as the person involved. The Administrator then brought the CNA into the room and questioned both together; at that time, the resident denied the allegation. The Administrator later confirmed that the allegation had been reported to her on January 9th, but she did not report it to the state agency or complete an investigation because the resident denied the allegation during that joint interview.
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