Failure to Timely Report and Investigate Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure timely reporting and investigation of an allegation of abuse involving one cognitively intact resident. The resident’s MDS dated 10/28/25 showed a BIMS score of 15, indicating intact cognition. On 12/21/25, documentation on an SBAR form indicated the resident sustained a skin tear while being changed and performing ADLs, with a note that the resident was accidentally bumped on the side rail. A Special Problems entry the same day, signed by CNA 3, documented that the resident screamed an expletive and said, "you hit me," and that CNA 3 responded that she did not hit the resident and that the resident hit herself on the siderail. A nurse’s note dated 12/23/25 indicated that an SOC 341 was completed because the resident claimed she was hit on the right hand and sustained a skin tear during ADLs, showing a delay between the allegation and formal reporting. During interviews, the resident stated that on 12/21/25 two CNAs provided care, that one CNA was gripping her and told her she screamed too much and should say please and thank you, and that her hand was injured during care, prompting her to tell the CNAs, "you hit me." On observation, a scab the size of a dime was noted over the pinky finger knuckle of the resident’s right hand. CNA 2 and CNA 3 both confirmed that during care on 12/21/25 the resident was injured, that they believed she hit herself on the bedrail, and that the resident told them, "you hit me." Both CNAs acknowledged they did not report the resident’s allegation of being hit. The DON confirmed that the resident made allegations to CNA 2 and CNA 3 that they hit her and that these allegations were not reported, despite the CNAs having been trained on reporting abuse. The facility’s Abuse Prevention Program policy required that alleged or suspected abuse be reported to specified parties and agencies within 24 hours and that residents be protected from harm by ensuring the accused perpetrator was not near the resident, measures that were not followed in this case.
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