Failure to Timely Report Allegation of Physical Abuse to State Agency
Penalty
Summary
Facility staff failed to report an allegation of physical abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse and neglect policy, dated 06/12/24, defined physical abuse as handling a resident with more force than is reasonable and required that all alleged violations involving abuse be reported immediately, but no later than two hours after the allegation is made if the events involve abuse or result in serious bodily injury. The facility census was 227. Review of the DHSS complaint/facility self-report database showed no documentation that the facility reported the allegation of physical abuse involving one resident. During an interview, the administrator stated that all allegations of abuse should be reported to DHSS within two hours and acknowledged responsibility for submitting the report. The resident involved had an annual MDS dated 01/06/26 showing he/she was cognitively intact, independent with ambulation, and had diagnoses including unspecified impulse disorder, schizoaffective disorder bipolar type, and ADHD. In an interview on 02/18/26 at 12:18 P.M., the resident reported that on the previous night a CNA held him/her by the coat collar at the neck area with a fist and slammed him/her against a wall near a doorway; the resident reported no injury and was unsure if there were witnesses. The facility’s investigation documentation, dated 02/18/26, recorded that the resident reported on 02/17/26 at approximately 7:38 P.M. that the CNA grabbed and pushed him/her, and that there were no direct witnesses and no injuries. The administrator reported being notified of the allegation at approximately 8:00 P.M. on 02/17/26 by an LPN, began an online report to DHSS, but closed the computer without confirming that the report was successfully submitted, resulting in the failure to report the abuse allegation within the required timeframe.
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