F0609

D

Failure to Report Resident’s Abuse and Neglect Allegations to State Agency

Globe, Arizona Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its abuse and neglect reporting policies and to timely report allegations of neglect to the state agency for one resident. The resident had multiple medical diagnoses, including type 2 diabetes mellitus, depression, urinary retention, benign prostatic hyperplasia, muscle spasm, and morbid obesity due to excess calories. A care plan initiated in February 2024 identified a risk for change in mood or behavior related to medical conditions, with interventions including medications as ordered. A quarterly MDS assessment documented intact cognition with a BIMS score of 15/15 and noted that the resident experienced depressed mood and behavioral symptoms in the days preceding the assessment.

The resident’s care plan for risk of change in mood and behavior was revised in February 2025 to note that the resident made untrue statements about receiving medications on time. On a date in February 2026, a behavior progress note documented that the resident told a medication technician he was being neglected and wanted to speak to a nurse immediately. The note indicated the allegation was reported to the DON, who spoke with the resident and instructed staff to provide care with two staff present in the room; however, there was no evidence that this allegation was reported to the state agency. The care plan was later revised to include interventions for two-person care and medication pass. Another behavior progress note in February 2026 recorded that the resident complained of not receiving nighttime medications and accused staff of abusing and neglecting him, and the nurse documented that the ADON was notified and that medications were being administered per physician orders. A separate note the same day indicated that care in pairs was continuing.

During interviews, the resident stated that an LPN had inflicted mental abuse on him through prior interactions that made him feel less than a man, and that he experienced increased anxiety and anxiety attacks when aware that this LPN would be on shift. He also reported feeling abused and neglected due to his race and said he had informed the DON but felt nothing was done. CNAs reported that the resident had shared allegations of abuse and neglect with them and that they relayed these concerns to nurses, who responded that they were already aware and would handle the matter; the CNAs were unsure what actions were taken. An LPN stated that allegations of abuse and neglect, including verbal and physical abuse and withholding care, must be reported to the state agency within two hours and that she had reported the resident’s allegations about water restrictions and medications to the ADON, DON, and Administrator, but she was not informed of any subsequent facility actions.

The DON stated that all allegations of abuse and neglect, including verbal abuse, were to be reported to the abuse coordinator, and acknowledged that a prior allegation of neglect documented in a June 2024 progress note had not been reported to her, and therefore was not reported to the state agency as required by policy and regulation. Regarding the February 13, 2026 progress note, the DON confirmed that the allegation of neglect had been reported to her but that she did not document any discussion with the resident. The DON, ADON, and Social Services confirmed that a conversation about the allegations occurred but was not documented and that they determined the allegation did not meet their understanding of abuse or neglect and did not require further action, including reporting to the state agency, contrary to facility policy and regulatory requirements. Social Services noted the resident had increased depression and anxiety and did not connect these behaviors with the abuse and neglect allegations. The facility’s policies on abuse identification and on reporting and response required staff to report suspected abuse, neglect, or exploitation to leadership and mandated that all alleged violations, whether oral or written, be reported to the facility and appropriate officials within prescribed timeframes, which did not occur in this case.

An LPN identified as the alleged perpetrator stated that whether she would report an allegation depended on who made it and the rapport she had with the resident, indicating she would decide what to report based on that relationship. She also stated she could not recall the resident disclosing allegations of abuse or neglect to her or against her and denied that any such allegations would be true based on her character. She did not describe specific actions or behaviors that would constitute abuse or neglect. Overall, the documented allegations by the resident, the staff interviews, and the policy review show that multiple allegations of abuse and neglect were not reported to the state agency and were not handled in accordance with the facility’s written abuse and neglect reporting policies and regulatory requirements.