Failure to Report Resident’s Allegation of Potential Abuse
Penalty
Summary
The facility failed to immediately report an allegation of potential abuse involving one resident. The resident, who had diagnoses including metabolic encephalopathy, abnormalities of gait and mobility, and muscle weakness, and whose MDS documented severely impaired cognition but that she usually understood others, reported that a male staff member from the rehabilitation department had touched her inappropriately about two weeks prior. She stated she informed the Social Services Director (SSD) at that time and had also told three or four other staff members, though she could not recall who. The resident’s family member later reported to the Director of Staff Development (DSD) that the resident had described a male physical therapist at her bedside performing a movement “up and down” in a circular way without counting, which made the resident feel very nervous and scared and not want to see or be near him, though she was not refusing therapy in general. Despite these reports, multiple staff members did not recognize or act on the information as an allegation of potential abuse and did not report it to the State Agency as required by facility policy. The DSD acknowledged that the family member had told her about the allegation but stated she did not ask the resident for additional details, did not investigate the identity of the therapist, and did not consider it an allegation of abuse, so she did not report it. The SSD stated the resident had mentioned an incident with a male therapist and feeling uncomfortable but the SSD did not clarify what happened, did not ask why the resident felt uncomfortable, did not investigate, did not document the report, and did not report it to the State Agency. The Director of Rehabilitation (DOR) stated he was informed the resident felt uncomfortable but did not know which therapist was involved, did not investigate to identify the therapist, and did not report the allegation. The Administrator stated he was told only that the resident was uncomfortable and preferred a certain therapist, believed no formal allegation had been received, and confirmed the incident was not reported. These actions and inactions were inconsistent with the facility’s abuse prevention policy, which required all allegations of abuse, neglect, misappropriation, or exploitation to be reported immediately to the Administrator and to appropriate State or Federal agencies within required timeframes.
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