F0609

D

Failure to Report Alleged Staff-to-Resident Abuse and Neglect to Required Agencies

Mesa, Arizona Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The facility failed to report an incident involving alleged staff-to-resident abuse and neglect to the required state agencies after a resident and his wife reported concerns about his care. The resident had multiple significant medical conditions, including hemiplegia and hemiparesis, protein-calorie malnutrition, facial weakness, dysphagia, muscle weakness, aphasia following cerebral infarction, cognitive, social, or emotional deficit, frontal lobe and executive function deficit, atrial fibrillation, hydrocephalus, convulsions, and headache. An admission MDS showed a BIMS score of 14, indicating intact cognition, and documented that the resident had exhibited rejecting care behaviors for 1–3 days. A care plan focus was initiated for risk of alteration in psychosocial well-being related to staff failure to honor resident choices during care on a prior date.

On a later date, the Executive Director (ED) completed a handwritten Concern & Comment Form after the resident stated he felt neglected because he had been left in a wet brief for a few hours and requested that law enforcement be called for neglect. The ED documented that the resident and his wife reported that he did not receive care upon arrival from the hospital, and the ED’s investigation concluded that the resident had received care throughout the night, including at midnight and when his feeding pump was checked. The ED recorded that the concern was resolved at the time it was shared and that the resident was informed that a specific RN would no longer provide his care, as requested. The facility’s internal investigation included obtaining written statements from staff about the incident.

In a subsequent interview, the resident’s wife stated that during the night in question, an RN and a CNA responded to the resident’s call light after he spilled his bedside urinal and that they turned him aggressively during a brief change, ignored his requests to stop, and then ignored him for the rest of the night, leaving his bed remote out of reach. She reported that two police reports were filed during his stay, one for an earlier incident and another for this night, and asserted that the later incident was not reported by the facility to any state agency except the police. The ED confirmed that he was aware of the allegation of neglect made by the wife, that he spoke with both the wife and the resident, and that the resident contradicted the wife’s allegation. The ED stated that, because he had conflicting statements and did not deem the later incident to be abuse, he did not report it to the State Survey Agency, APS, or other required state entities, despite facility policy requiring that all alleged violations be reported within specified timeframes regardless of how they are characterized.

Additional staff interviews showed that staff were aware of the requirement to report allegations of abuse and neglect promptly to facility leadership. The RN identified as involved denied that any allegation of rough care or neglect had been made to or about her and denied ignoring the resident or making threatening statements. Other CNAs and an LPN recalled that the resident had a history of making allegations, that he was to receive two-person care, and that there had been prior incidents involving staff being fired. One CNA reported being contacted by the previous DON and asked to provide a written statement after the resident alleged that night-shift staff had neglected him. The facility’s abuse and neglect policies defined abuse and neglect broadly and required that all alleged violations, whether oral or written, be reported immediately (within 2 hours if abuse or serious bodily injury was involved, or within 24 hours otherwise) to the administrator and appropriate state officials, and that staff did not need to explicitly label an event as abuse or neglect for it to be considered reportable. Despite these policy requirements, the ED acknowledged that the later allegation of neglect was not reported to the required state agencies.