Failure to Report Alleged Staff-to-Resident Abuse to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the state agency as required by its own abuse, neglect, and exploitation policy and state regulations. The facility policy defined abuse, including verbal abuse, and required that all alleged violations be reported to the Administrator, state agency, Adult Protective Services, and other required agencies within specified timeframes. Resident 4, who had hemiplegia following a stroke, aphasia, dementia, and required staff assistance for daily care, was usually able to understand and be understood. A grievance decision report documented that the resident’s daughter reported the resident had used hand gestures indicating that a nurse was rough when rolling him and told him to “shut up.” The daughter stated the resident, who does not communicate well, repeatedly said “shut up” sixteen times and referenced “night shift, heavy set, older,” and that the incident likely occurred between a Saturday night and the following Tuesday. The facility’s internal grievance investigation noted that an LPN recalled the resident telling her about someone being rough and that the resident described the staff member as having dark hair. The Assistant Director of Nursing identified this night-shift nurse as LPN 1 and stated that LPN 1 reported the resident only said someone was rough with him and did not mention being told to “shut up.” The Social Worker reported that the daughter relayed the allegation the evening before the resident’s planned discharge, and that she and the Assistant Director of Nursing took notes and developed a suspicion about who the alleged perpetrator might be based on the description and staff interviews, but could not positively identify the individual. Administration was aware of the allegation on January 27, 2026, but the resident was not interviewed about the allegation before discharge, and the allegation was never reported to the Department of Health. The Assistant Director of Nursing confirmed that LPN 1 did not immediately report the allegation as required and that the facility failed to report the allegation to the state.
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