Failure to Accurately Report Resident Abuse and Alleged Neglect to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to accurately and completely report a resident‑to‑resident physical abuse incident to the Abuse Coordinator and State Agency. The Facility Reported Incident submitted on 11/3/25 described only that physical contact was made by one resident toward another, that one‑on‑one supervision was initiated, and that an investigation began, but it did not document the type of physical contact. In contrast, the nursing progress note for the involved resident documented that a CNA reported one resident rolled up to another in the dining area, grabbed the resident by the collar, pulled her to the floor, and that the resident had pain in her right arm and hip. The internal investigation file further documented that the incident occurred in the dining room, that the resident fell from the wheelchair related to the incident, and that the aggressor approached from behind and made physical contact resulting in the fall. During interview, the CNA witness stated that the aggressor grabbed the other resident out of the chair by her shirt, would not let go, the resident fell to the floor, and the aggressor continued swinging with one arm until separated by staff. The Administrator, who served as Abuse Coordinator, acknowledged that the report to the State Agency should have contained more detail to explain what actually happened. The deficiency also includes the facility’s failure to report an allegation of neglect involving staff response to a resident’s call light. A Concern Form dated 8/4/25 documented that a resident alleged when the call light was pressed, staff turned off the call light from the desk without completing the requested task. The form recorded a verbal statement from a nurse during the Administrator’s investigation in which the nurse admitted to turning off the call light without addressing the resident’s issues. In a subsequent interview, the Administrator confirmed recalling the incident, identified the nurse who admitted to turning off the call light from the nursing station without checking on the resident, and stated that this allegation of neglect was not reported to the State Agency. The residents involved had significant medical and functional impairments. One resident in the abuse incident had diagnoses including lupus, anxiety disorder, major depressive disorder, auditory hallucinations, cerebral palsy, and legal blindness, with an MDS showing moderately impaired cognition. The other resident in that incident had a history of brain injury and epilepsy with severely impaired cognition. The resident alleging neglect of call light response had quadriplegia and used a specialized breath‑activated call light, with additional diagnoses including peripheral vascular disease, chronic pain, pressure ulcers, neuromuscular bladder dysfunction, and a suprapubic catheter. This resident reported that staff were still turning off the call light from the nursing station, explaining that the hallway bell would stop sounding and no one would come to the room, indicating the light had been deactivated from the desk. The facility’s abuse policy required that all allegations of abuse and neglect be reported immediately to the Administrator and to the State Survey Agency within specified time frames, but the described events were not reported in accordance with that policy and regulatory expectations.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.