Failure to Notify Physician and Family After Alleged Staff-to-Resident Abuse
Penalty
Summary
Facility staff failed to notify the physician and the resident’s responsible party after an allegation of staff-to-resident abuse. The facility’s policy on “Change in a Resident’s Condition or Status,” revised February 2021, required prompt notification of the physician and resident representative for changes in the resident’s medical or mental condition and/or status. A certified nursing assistant (CNA) was alleged to have slapped a resident on the leg while providing care. Review of the resident’s progress notes from 1/27/26 to 2/4/26 showed no documentation that the physician or family had been notified of this allegation. The administrator stated that he/she expected the physician and family to be notified when there are allegations of employee-to-resident abuse but could not locate any progress note or incident report documentation showing that such notifications occurred. The resident involved had a Significant Change MDS dated 12/09/25 indicating severe cognitive impairment, daily rejection of care, complete bowel and bladder incontinence, and diagnoses of non-Alzheimer’s dementia and depression. During interview, the resident’s family member reported that facility staff did not notify him/her about the abuse allegation and that he/she only learned of it the following day during a visit, when the administrator asked if he/she knew about the incident. In a separate interview, the nurse practitioner confirmed having no record of, and not receiving, any call from the facility regarding the CNA slapping the resident during care. These findings demonstrate that required notifications to the physician and resident representative were not made or documented following the abuse allegation.
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