Failure to Report Resident Abuse Allegation to Required Authorities
Penalty
Summary
The facility failed to report an allegation of abuse to Adult Protective Services, the Long-Term Care Ombudsman, local law enforcement, and the state survey agency, and failed to complete the required 5-day follow-up report to the state agency. Facility policy on Abuse, Neglect and Exploitation, dated 6/2025, requires that all alleged violations be reported to the Administrator, state agency, APS, and all other required agencies within specified timeframes: immediately but no later than 2 hours if the allegation involves abuse or results in serious bodily injury, or within 24 hours if it does not. The policy also requires the Administrator to follow up with government agencies to confirm receipt of the initial report and to report the results of the investigation within 5 working days. Despite these requirements, there was no documentation that the allegation involving one resident was reported to any of the required external authorities or that a 5-day follow-up was completed. The resident involved was admitted with diagnoses including diabetes, hypertension, sepsis, and PTSD, and was documented as cognitively intact with a BIMS score of 13. On the night in question, the resident reported that a blonde CNA on night shift jerked her diaper off and slapped or tapped her inner thigh and arm during incontinence care, and later told a PTA that the CNA was mean to her, had slapped her leg and arm, and that she did not feel safe. The PTA immediately notified the Unit Manager, who in turn notified the Administrator and DON and initiated an internal investigation. The former DON confirmed awareness of the allegation and acknowledged that such allegations should be reported to the state, stating she thought the Administrator had reported it. The Administrator confirmed the allegation was not reported to the state agency and acknowledged that, under federal regulations, an allegation of abuse should have been reported within 2 hours of facility knowledge.
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