Failure to Report Alleged Physical Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was reported to the State Agency as required by its own policy and by federal and state law. The facility’s abuse policy required that all alleged violations involving abuse be reported immediately, and no later than two hours after the allegation is made if the events involve abuse. A resident with vascular dementia, major depressive disorder, anxiety disorder, pain, and severe cognitive impairment (BIMS score 03/15) was involved in an incident where an LPN tapped or smacked the resident’s buttocks while the resident was at the nurses’ station wearing only a gown and brief, with her backside exposed toward the dining area. Documentation showed that when the nurse tied the gown and tapped the resident on the bottom, the resident said, “don’t do that, I don’t like that,” and, according to a CNA interview, the nurse smacked the resident’s brief a second time, prompting the resident to raise her fist and repeat that she did not like it. The incident occurred on or about 1/9/26, but review of the resident’s electronic medical record and incident reports revealed no documentation of the incident or any follow-up investigation in the resident’s chart, and the incident was not reported to the State Agency. The Executive Administrator acknowledged that this was an allegation of abuse that should have been reported immediately and was not. The DON, who investigated the incident, stated that she did not report it because she determined the LPN acted “in fun” and did not intend to hurt the resident. Interviews with the LPN and CNA corroborated that the LPN tapped or smacked the resident’s buttocks, that the resident verbally objected, and that the LPN repeated the action and laughed, making at least one CNA feel uncomfortable. Despite these facts and the facility’s written policy requiring immediate reporting of alleged abuse, the allegation was not reported to the State Agency.
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