Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an alleged incident of abuse was reported to the State Agency within the required 2-hour timeframe after the allegation was made. Facility policy, titled “Abuse Prevention Program” and effective 1/23/26, requires that all alleged violations involving abuse be reported immediately, but not later than two hours, to the State Agency and other appropriate agencies. Despite this policy, the Nursing Home Administrator (NHA) did not report an allegation of physical abuse involving a resident and a CNA until several hours after first being informed of the concern. The resident involved, identified as R6, had been admitted on 6/25/2015 with diagnoses including post-traumatic stress disorder and had a legal guardian. R6’s most recent MDS documented a BIMS score of 15, indicating intact cognition. On the evening of 2/9/26, around 7:30 PM, R6 reported to an LPN that a CNA had grabbed R6’s arm and that R6 felt the CNA’s nails on the skin. The LPN stated that shortly after receiving this report, the LPN contacted the NHA and the DON, asking what should be done. The LPN reported being instructed by the NHA to obtain a statement from the resident and perform a skin check, which the LPN completed and provided to the NHA. The NHA acknowledged receiving a text from the LPN around 11:00 PM on 2/9/26 asking what to do if a resident reports abuse, and directed the LPN to get a statement and send it. The NHA stated that no information about potential physical contact was received until the morning of 2/10/26 and that the allegation was reported to the State Agency at 6:16 AM on 2/10/26 via email after the reporting website was not working. Surveyor review of the Facility Reported Incident showed the initial allegation of abuse was submitted to the State Agency at 2:16 PM on 2/10/26. The surveyor determined that the facility did not ensure the alleged violation involving abuse was reported to the State Agency immediately, and not later than 2 hours after the allegation was made, as required by facility policy and regulatory requirements.
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