Failure to Report Staff-Reported Abuse Allegation to Required External Authorities
Penalty
Summary
The deficiency involves the facility’s failure to timely notify law enforcement, the ombudsman, and the state agency after a staff-reported allegation of abuse involving one resident. The resident, admitted with dementia and anxiety, had documented short- and long-term memory problems. On the date of the incident, a CNA reported to an LVN that the resident’s husband was rough and upset with the resident for not sitting in a wheelchair to go to the dining hall and made a gestured motion toward the resident’s face; the CNA observed the resident appearing shaken and fidgeting afterward. A change of condition note documented the incident involving the husband, resident, and CNA, and the MD recommended monitoring the resident for signs and symptoms of emotional distress. The resident’s care plan was updated with an entry for an alleged hand gesture to the resident’s face with interventions. In subsequent interviews, the LVN supervisor confirmed the change of condition documentation and stated that, based on the facility’s investigation concluding no abuse occurred, he did not report the allegation to required external entities and was unsure if the facility reported it at all. The LVN who received the initial report stated she separated the husband from the resident, reported the allegation to the LVN supervisor, and that the supervisor immediately began an investigation and discussed it with the administrator and DON, but she did not know if it was reported outside the facility. The CNA later stated he witnessed the husband push the resident into a wheelchair and punch the resident’s face near the chin area, saw the resident’s body shaken and fearful, and believed it was abuse that should have been reported. The DON and regional administrator both acknowledged that, based on their determination that no abuse occurred and the husband’s denial, the allegation was not reported to the ombudsman, law enforcement, or state agency, despite facility policy requiring immediate reporting of suspected abuse to these entities.
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