Failure to Timely Report Allegation of Verbal and Physical Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe as outlined in its own Abuse, Neglect, Misappropriation, Mistreatment, and Exploitation policy. The policy, updated on 08/25/2023, required that all allegations of abuse or serious bodily injury be reported to the Department of Quality Assurance immediately, but not later than two hours after the allegation is made. Resident #1, who had intact cognition with a BIMS score of 14, a history of lumbar osteomyelitis, discitis, anxiety disorders, muscle weakness, right thigh pain, and chronic bilateral hip and acute back pain, was dependent on staff for toileting hygiene and repositioning and experienced frequent pain that affected sleep, therapy, and daily activities. The resident’s care plan directed staff to anticipate and respond immediately to pain complaints and to check and change the resident frequently. On 10/09/2025 at 5:00 PM, an allegation of abuse occurred when RN A was observed by the Interim DON telling Resident #1, "you just need to knock it off or therapy will cut you and we will throw you out," which upset the resident. During the investigation, the Administrator learned from staff statements that RN A had forced the resident to receive incontinence care after being alerted by the resident’s crying out during care. The Administrator acknowledged being informed of the allegation on 10/09/2025 but submitted the Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report to the state agency on 10/10/2025 at 11:00 AM, 18 hours after the allegation. The Administrator stated he believed that, because the allegation did not involve physical bodily injury, it only needed to be reported within 24 hours and admitted the initial report was not filed within two hours and that he was not aware this was required by facility policy. The Former DON stated that she and the Administrator were made aware of the incident during the morning meeting on 10/10/2025, indicating a delay in internal reporting and external notification compared to the policy’s immediate reporting requirement.
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