Failure to Timely Report Resident Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse within the required time frame after a cognitively intact resident reported being physically abused by a CNA. The resident, who had a BIMS score of 15 indicating intact cognition, alleged that on the evening of 1/3/26 a CNA verbally assaulted him, slapped him, pushed him into bed, and choked him during provision of care. A scheduled skin assessment on 1/5/26 documented no bruising or finger marks, and later assessment found no signs or symptoms of injury. The resident’s care plan noted a history of making accusatory statements about non-Caucasian staff and a preference for Caucasian staff, with a statement that all such reports would be taken seriously and investigated per policy. On the morning of 1/5/26, during the resident’s bath, he told a CNA that he had been physically abused by the CNA involved on 1/3/26. That CNA reported the allegation to the social services director the same morning. The social services director then reported the allegation to the interdisciplinary team meeting held that day and indicated that, after her report, the matter was to be handled by the administrator. Despite this, the administrator later acknowledged that she did not follow up with the resident on 1/5/26 when the allegation was reported, but instead waited until 1/6/26 to do so. Additional interviews further documented the resident’s repeated reports of the alleged abuse. On 1/8/26, while being checked on by an LPN/care coordinator, the resident again stated that over the weekend a “black lady” CNA had pushed him down on his bed while assisting with care. On 1/9/26, during an in-person interview with a counselor, the resident reported that the CNA became physical with him during his evening cares on 1/3/26, while also stating he had a sense of safety in the care setting and denied feeling intimidated by others. The facility’s abuse policy required that all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property be reported to the state survey agency immediately but not later than 2 hours, based on real clock time. The failure to ensure that this resident’s abuse allegation was reported to the state within the required time frame constituted the cited deficiency.
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