Failure to Timely Report Resident’s Allegation of Physical Abuse to State Agency and Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse reporting policies and federal requirements under section 1150B of the Act when an allegation of physical abuse was made by a resident and not reported to the State Agency or local law enforcement within the required 2-hour timeframe. The facility’s Resident Safety Abuse Policy, reviewed in 03/24, states that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of resident property must be reported immediately, but not later than 2 hours after the allegation is made, to the administrator, who will ensure reporting to the State Survey Agency and other officials. Despite this policy, the facility did not submit a Facility Reported Incident (FRI) to the State Agency or contact local law enforcement within 2 hours of the allegation. The resident involved had diagnoses including degeneration of the nervous system due to alcohol, convulsions, hepatic failure, altered mental status, major depressive disorder, anxiety disorder, thiamine deficiency, and cerebrovascular disease. On 02/03/26 at 9:38 PM, progress notes documented that the resident was found in a wheelchair with genitals exposed, made sexually suggestive comments to staff, became physically aggressive by pushing and grabbing the nurse’s arm, lunged at a CNA, attempted to block the exit, and shouted threats toward staff. Later, the resident went to the nursing station, accused the nurse of threatening and coming at their throat, and demanded that the police be called. The Nursing Home Administrator was called and arrived, but the facility did not contact local law enforcement and did not submit the FRI to the State Agency until 02/04/26 at 6:47:28 PM. During interview, the administrator acknowledged that the allegation was considered abuse, that the FRI was sent the next day, that law enforcement was not called, and that the facility’s policy for reporting within 2 hours was not followed because the administrator believed the allegation did not occur, even though the full investigation and interviews were not completed until the following day.
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.