Failure to Timely Report Resident’s Abuse Allegation Involving Required Assistance With Toileting
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of verbal and potential physical abuse involving one resident. The facility’s abuse policy, revised 10/20/2022, required all alleged violations involving abuse to be reported immediately, but not later than two hours after the allegation was made, to the administrator or designee and to state officials, including the state survey agency and adult protective services. The Nursing Home Guidelines (Purple Book) also required staff-to-resident allegations to be reported to the DSHS Hotline, logged within five days, and reported to police or 911. Resident 1, who had diagnoses including myocardial infarction, sepsis, unsteadiness on feet, muscle weakness, cardiomyopathy, and a recently placed AICD with instructions not to use the left arm, was moderately cognitively impaired per the 5-day MDS. On 03/07/2026, a facility incident investigation documented that an RN (Staff F) assisted the resident to the bathroom and told the resident they needed to transfer themself to and from the toilet, and when the resident asked if Staff F would return to help them off the toilet, Staff F stated the resident would have to transfer themself or stay there forever. Later that evening, a CNA (Staff E) answered the resident’s call light and found the resident in the bathroom; the resident reported they had already transferred and cleaned themself because Staff F had told them to do it themself or stay there forever. Staff E reported this concern only to the oncoming CNA at shift change and did not notify a supervisor, stating they did not report the allegation because the resident asked them not to. The next day, another CNA (Staff G) documented that the resident reported significant left arm pain and disclosed the prior day’s allegation, which Staff G then reported to their supervisor. Interviews confirmed that Staff E had recently received abuse training, including instruction to report all allegations of abuse and to report them within two hours to the abuse coordinator and/or supervisor, and that abuse should be reported even if a resident requests that it not be. The facility failed to follow its own policy and regulatory requirements for immediate reporting of an abuse allegation when Staff E did not escalate the resident’s report beyond informing the oncoming CNA.
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