Failure to Timely Report Resident’s Allegation of Staff Mistreatment
Penalty
Summary
The facility failed to report a resident’s allegation of potential abuse to the State survey agency and the Nursing Home Administrator within the timeframes required by its abuse, neglect, and exploitation policy. The policy, last reviewed on 11/5/25, requires all alleged violations to be reported to the Administrator, State agency, adult protective services, and other required agencies within 2 hours if the allegation involves abuse or serious bodily injury, or within 24 hours if it does not. On 1/1/26 at 6:12 a.m., an RN documented that the resident requested to see the nurse during the night shift and complained about two night-shift CNAs who performed ADL care, stating he wanted the matter reported. The RN notified the DON and obtained CNA statements, but there is no documentation that the allegation was reported to the State agency or the Nursing Home Administrator. The resident involved had diagnoses including cervical radiculopathy, benign prostatic hyperplasia, adult failure to thrive, pulmonary hypertension, and depression, and was cognitively intact with a BIMS score of 15. The MDS documented that the resident was dependent on staff for toileting hygiene and transfers, required substantial/maximal assistance for rolling, and was always incontinent of urine with a colostomy. During an interview with the Surveyor, the resident described an incident on New Year’s Day in which two female staff insisted on changing him despite his statement that he was not wet, and he alleged that one staff member held his wrists and pulled him, hurting his shoulder, while the other removed his brief. He reported telling the nurse that staff had “roughed him up” and that something had to be done, and confirmed he told the nurse that his wrists were held down. The RN later confirmed to the Surveyor that the resident complained about how staff were trying to change him and wanted to make a report, and that this was reported to the DON. The NHA stated she was not notified of the allegation and confirmed there had been no facility-reported incidents to the State agency for this resident in the last six months.
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