Failure to Timely Report Alleged Staff-to-Resident Abuse to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of staff-to-resident abuse to the State Survey Agency (DHSS) within the required two-hour timeframe after staff became aware of the allegation. Facility policy, dated March 2016, required that any and all cases of alleged resident neglect, abuse, or misappropriation of resident property be reported immediately, but not later than two hours after forming the suspicion, to the hotline and/or DHSS. Multiple staff, including LPNs, CNAs, the ADON, and the Administrator, acknowledged in interviews that the facility had two hours to report abuse allegations to the State and that rough care and cursing constituted abuse that should be reported immediately. The resident involved had been admitted with diagnoses including Parkinson’s disease, COPD, atrial fibrillation, and dementia, with moderate cognitive impairment, wheelchair use for mobility, and frequent bowel and bladder incontinence. The resident’s care plan noted cognitive impairments related to psychotropic medications and risk for falls due to weakness, medications, and gait disturbance. On a late afternoon, the resident’s family member reported to an LPN, in the presence of another LPN, that the resident said a male CNA working the night shift had tossed the resident roughly into bed and cursed at the resident, and demanded that this CNA no longer provide care. The LPN documented this allegation in a handwritten statement and immediately notified the DON. Despite this immediate internal reporting, the DON did not promptly notify the Administrator or DHSS. The DON stated that the family “was complaining to complain” and did not contact the Administrator until the following night, more than 24 hours after the allegation was reported to facility staff. The Administrator then became aware of the allegation and, on a later morning, notified DHSS, the Ombudsman, and the police, and initiated interviews. DHSS records confirmed that the facility self-reported the allegation two days after staff first became aware of it. Both the DON and the Administrator acknowledged that the allegation of rough care and cursing constituted physical and verbal abuse and that it should have been reported to DHSS immediately, within the two-hour requirement, which did not occur.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.