F0609

D

Failure to Timely Report Allegation of Abuse to State Agency

Fort Atkinson, Wisconsin Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to report an allegation of abuse within the required two-hour timeframe to the state survey agency. Facility policy titled “Abuse, Neglect, and Exploitation,” dated 10/01/2022, required that all alleged violations involving abuse or resulting in serious bodily injury be reported immediately, but not later than two hours after the allegation is made. The resident involved had been admitted with a history of Parkinson’s disease, depression, anxiety disorder, somatization disorder, personality disorder, and Alzheimer’s disease, and an admission MDS showed a BIMS score of 12, indicating moderate cognitive impairment. The resident’s care plan documented behavioral symptoms such as verbal aggression, combativeness, throwing objects, refusing care and therapy, calling 911 for nonemergent needs, accusatory behavior toward staff, and delusions.

On the date of the incident, a Misconduct Incident Report documented that at approximately 3:30 PM the resident reported being hit by staff and having a bloody nose. The facility submitted this report to the state survey agency at 9:16 PM the same day, more than five hours after the allegation was made, contrary to the policy requirement for reporting within two hours. In an interview, the previous Executive Director acknowledged not reporting the allegation within two hours and stated he was following direction from the Corporate Lead. The DON stated that any abuse allegation should be reported to the ED immediately and then to the state survey agency within two hours, and confirmed that the report related to this allegation was not submitted timely, without knowing the reason. The current ED also stated that all abuse allegations must be reported to her immediately and then to the state survey agency within two hours.