F0607

E

Failure to Report and Act on Allegation of Physical Abuse

Moses Lake, Washington Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its abuse prohibition policy and mandated reporting requirements after an allegation of physical abuse involving Resident 1. The facility’s written policy, dated 10/24/2022, prohibited abuse, defined physical abuse as including hitting and slapping, and required any staff who witnessed suspected abuse to immediately tell the abuser to stop and report the incident to a supervisor, who in turn was to immediately notify the Administrator. The policy also designated all employees as mandated reporters who must immediately report any reasonable suspicion of a crime against a resident, required the immediate removal from duty of any employee alleged to have committed abuse, and required the Administrator to report allegations to the State Survey Agency and local authorities within two hours of receiving a report.

Resident 1 had multiple significant medical conditions, including stroke with hemiparesis, dementia, bipolar disorder, and an anxiety disorder, and required extensive assistance with bed mobility and toilet hygiene. The resident had an indwelling urinary catheter, bowel incontinence, and a Stage 4 sacral pressure ulcer requiring dressing changes. During a dressing change following a bowel movement that soiled the wound dressing, Staff D, a NA in training, reported observing Staff B, the Director of Nursing Services, slap Resident 1 on the bare buttock after completing the dressing change. Resident 1 reportedly asked what the slap was for, and Staff B replied it was “just to let you know I was done.” Staff D stated they felt very uncomfortable with what they witnessed and later told the other two NAs in the room they intended to report the incident to the hotline, but did not do so until about 30 days later, after leaving employment at the facility.

Multiple staff who were aware of the incident did not follow the facility’s abuse reporting policy. Staff E and Staff F, both NAs present in the room, acknowledged witnessing Staff B slap the resident’s bare buttock but stated they did not consider it abuse and therefore did not report it to the Administrator or the state hotline. Staff C, an RN Resource Clinician, stated that Staff B later told them they had tapped Resident 1 on the butt cheek and that the staff in the room looked at them “funny,” but Staff C did not take the matter further. The Administrator reported having received no prior reports of inappropriate behavior by Staff B and was unaware of the incident until informed by the surveyor. As a result, the facility did not identify the incident as a reportable allegation of abuse, did not immediately notify the Administrator or SSA, and did not remove the alleged perpetrator from duty or initiate an investigation in accordance with its policy and WAC 388-97-0640.