Failure to Report Allegations of Abuse and Exploitation to State Agency
Penalty
Summary
The facility failed to report allegations of abuse and exploitation to the State Agency as required by its Abuse, Neglect and Exploitation policy. The policy, revised 7/1/25, required reporting all alleged violations to the Administrator, State Agency, Adult Protective Services, and other required agencies within specified timeframes, including within 2 hours for allegations involving abuse or serious bodily injury and within 24 hours for other allegations. A cognitively intact resident, with a BIMS score of 14/15 and diagnoses including drug-induced adrenocortical insufficiency, rheumatoid arthritis, anxiety, and depression, filed a grievance on 2/6/26 stating that a CNA told the resident they could not get out of bed if they only wanted to be up in a wheelchair for an hour. The DON confirmed the resident had reported that the CNA refused to get the resident into the wheelchair during an overnight shift if the resident only wanted to be up for an hour, and that the CNA later stated they had told the resident they might not be able to return in an hour due to assisting other residents. This allegation of abuse was not reported to the State Agency. The facility also did not report an allegation of exploitation involving the same resident and the same CNA. A progress note by the social worker designee documented that the resident had spoken with attorneys and was advised to inform the facility that the resident had given the CNA a tumbler as a gift, and that the resident knew they were not supposed to give gifts to staff. The DON stated that the resident had informed her that the resident purchased a mug for the CNA, who initially refused it multiple times but eventually accepted it due to pressure from the resident. During interviews, both the NHA and DON confirmed that allegations of exploitation should be reported to the State Agency, but this allegation was not reported, resulting in a failure to follow the facility’s own reporting procedures for abuse and exploitation.
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