F0609

D

Failure to Timely Report Alleged Physical Abuse to State Agency

Radcliff, Kentucky Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to report an allegation of physical abuse to the State Survey Agency (SSA) within the required two-hour timeframe. Facility policy titled “Reporting Abuse to State Agencies” required all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property to be reported immediately, but not later than two hours after the allegation was made, when the events involved abuse or resulted in serious bodily injury. A related policy, “Reporting Abuse to Facility Management,” required employees to immediately report any observed or suspected abuse to the on-duty supervisor, who was then to immediately notify the Administrator or Assistant Administrator. These policies reflected the regulatory requirement that all allegations involving abuse be reported within two hours.

The resident involved, R1, was admitted with diagnoses including Alzheimer’s disease with late onset, cognitive communication deficit, chronic kidney disease, and hypertension, and was assessed as severely cognitively impaired on the MDS. On 07/22/2025 at approximately 10:00 AM, Nurse Aide State Registered (NASR) 2 observed NASR1 in the bathroom with R1 and allegedly inappropriately pulling on R1’s arm while providing a shower, with R1 trying to pull away. NASR2 did not report the incident immediately; instead, she later told LPN1 around lunchtime that NASR1 had been rough with R1. LPN1 assessed R1 and observed marks on the arm consistent with grabbing, then reported the incident up the chain of command. Interviews and an investigation timeline confirmed that NASR2 delayed reporting because she was nervous and unsure it was abuse, and she was aware of others feeling retaliated against after reporting concerns.

The facility’s Initial Report, dated 07/22/2025, documented the incident time as 12:35 PM and showed that the allegation was reported to the Department for Community Based Services, the ombudsman, and the Office of Inspector General (OIG/SSA) at 2:32 PM. However, the Final Report/5 Day Follow-Up, dated 07/25/2025, clarified that the alleged abuse actually occurred at 10:00 AM, meaning more than four hours elapsed before the allegation was reported to the SSA. An internal investigation timeline showed that NASR1 remained in direct resident care until 12:32 PM, the Administrator was notified at 12:33 PM, the investigation was initiated at 12:50 PM, and the allegation was reported to OIG/SSA at 2:32 PM. The ADON and DON both acknowledged that they understood the incident had occurred around 10:00 AM and that abuse allegations were to be reported within two hours. The Administrator stated she believed the report was timely because she thought the two-hour requirement applied only when bodily injury was present, and did not recognize that the regulation and facility policy required all abuse allegations to be reported within two hours when the event involved abuse, resulting in the late reporting deficiency.