F0609

D

Failure to Timely Report Abuse Allegations and Notify Law Enforcement

Oconomowoc, Wisconsin Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely report allegations of abuse to the State Agency and to notify law enforcement, as required by regulation and by the facility’s own abuse policy. The facility’s policy on freedom from abuse, neglect, exploitation, and misappropriation directs that suspected abuse be immediately reported to a nursing supervisor, who must then notify the DON and NHA, and that the NHA report to the state within the allowed time frame and involve other regulatory authorities, including law enforcement, as needed. In the case of one resident, the facility did not report an allegation of staff-to-resident physical abuse to the State Agency within 2 hours and did not notify law enforcement at all. In a separate incident involving a resident-to-resident altercation, the facility submitted the initial abuse report to the State Agency more than 19 hours after the event and again did not contact law enforcement.

In the first incident, a resident with vascular dementia, generalized anxiety disorder, weakness, legal blindness, and moderate cognitive impairment (BIMS score of 9) alleged that a CNA pushed the resident against the wall and the bar of a Sara Steady device and slapped the resident in the face multiple times with a wet rag during cares around 12:30 a.m. The CNA reported that the resident alleged she had hit the resident and that she attempted to get the nurse but did not leave the resident due to the resident attempting to self-transfer; she then assisted the resident back to bed and reported the allegation to the RN. The RN assessed the resident, documented that the resident reported pain but had no visible swelling, redness, or bruising, and continued to provide care for the resident for the remainder of the shift while the CNA continued working her shift, though no longer caring for that resident. The RN did not notify the NHA or DON of the allegation during the shift and stated she viewed the situation as confusion rather than an abuse allegation, and she acknowledged she should have removed the CNA and reported the allegation to administration immediately. Law enforcement was not contacted, and the facility did not report the allegation to the State Agency within the required 2-hour timeframe.

In the second incident, a cognitively intact resident (BIMS score of 14) was seated at a dinner table across from another resident with Alzheimer’s disease, dementia with psychotic disturbance, and severe cognitive impairment (BIMS score of 4). During the meal, the cognitively impaired resident moved to the opposite side of the table, pulled the other resident’s hair, and shook the resident’s wheelchair. Staff present in the room intervened immediately and separated the residents, and an RN assessed the resident who was grabbed and found no injuries. The incident was documented as an allegation of abuse, but the initial Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report, Misconduct Incident Report was not submitted to the State Agency until the following morning at 9:10 a.m., approximately 19 hours and 10 minutes after the incident, exceeding the 2-hour reporting requirement. The facility did not contact law enforcement regarding this resident-to-resident altercation, and the DON confirmed that police were not notified because no injury occurred.