Failure to Timely Report Resident Abuse Allegation to Required Authorities
Penalty
Summary
The deficiency involves the facility’s failure to timely report and properly document a resident’s allegation of abuse to required facility leadership and external authorities. A resident with non-Alzheimer’s dementia and moderate cognitive impairment (Resident C) reported that another resident (Resident F) hit her left shoulder. She stated she informed a nurse and another staff member at the front of the building, and the nurse told her she would be okay. An RN heard a resident yell, “He hit me,” and found Resident C in front of the nurse’s station. The RN took Resident C back to her room, visually checked her shoulder, found no marks, did not complete a full skin assessment, and did not notify the Administrator or DON of the allegation. An LPN reported that in situations where a resident claims to be hit by another resident, she would verbally report to the Administrator and DON, and that floor staff do not document such occurrences, leaving documentation to management. The Administrator stated he was not informed of the incident until several days after it occurred. The Social Services Director reported that Resident C came to her holding her left shoulder and stating she had been hit by Resident F. The Social Services Director interviewed staff and created a “soft file” investigation document dated 03/20/2026, but did not report the allegation to the Administrator or DON. Review of the facility’s abuse policy, revised 06/05/2025, showed that care team members are required to immediately report all such allegations to the Administrator and to the Department of Health in accordance with the policy’s procedures. Despite multiple staff being informed of the allegation, the required immediate reporting to facility leadership and the Department of Health did not occur, and the Administrator only became aware of the allegation days later, at which point he had just begun his own investigation.
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