Other·April 30, 2025

REGULATION VIOLATION(S) 1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. 1418.91(b) A failure to comply with the requirements of this section shall be a class "B" violation. The facility failed to implement its policy and report an incident of alleged abuse to the Department of Public Health, when Administrative Staff A received an allegation of an employee-to-resident incident between one of two sampled residents (Resident 1) and a Certified Nursing Assistant (CNA) but did not advance the concern through the facility's system for reporting. This failure resulted in no report, no assessment of Resident 1's safety, and no investigation of the potential abuse concern, and did not ensure interventions could be initiated to protect Resident 1 or other residents from reoccurrence of the alleged abusive behaviors. During an interview on 6/16/21 at 10:34 a.m., Resident 1 stated she had turned on the call light because she had to urinate, but no one was coming to assist her so she urinated in her beverage cup. Resident 1 stated, when a CNA came into assist her, the CNA addressed her harshly and told her, "Don't you ever do that again." Resident 1 stated, when the CNA returned with new bed sheets, she yelled at Resident 1 and threw the bed sheets in Resident 1's face. During an interview on 6/30/21, at 3:51 p.m., Responsible Party B stated she notified Administrative Staff A of Resident 1's experience with a CNA on 12/25/20. During a concurrent interview and record review on 7/12/21, at 1:30 p.m., Administrative Staff A stated Responsible Party B emailed him on 12/25/20, to alert him about a night shift CNA who allegedly harassed or threatened Resident 1. Administrative A stated the facility's process after receiving an abuse allegation required notifying the facility's Director of Nursing Services (DON), who would initiate an investigation. Administrative Staff A stated, "Yes, the investigation should have taken place." Administrative Staff A stated a SOC 341 form (a state form used to report suspected dependent adult/elder abuse) describing the employee-to-resident abuse allegation should have been completed and sent to all authorities indicated. During a concurrent interview and record review on 7/12/21, at 2:15 p.m., Administrative Staff A and the DON were present. Administrative Staff A stated he did not forward the e-mail from Responsible Party B to the DON. The DON stated she was never informed of the alleged employee-to-resident abuse allegation. The DON stated, if she had been informed, she would have started the investigation. Administrative Staff A stated the alleged employee-to-resident abuse allegation should have been investigated. The facility police/procedure titled, "Suspected Abuse," undated, indicated: "Abuse Coordinator to ensure that the investigation is complete, and suspend suspected employee(s) during investigation. Abuse Coordinator to ensure the procedures in the abuse prevention manual are followed. Immediately call to inform Ombudsman, Licensing Agency, and the Local Police. Complete the SOC 341 and fax the SOC 341 to the Ombudsman, Licensing Agency, and the Local Police within 24 hours." Therefore, the facility failed to notify the Department within 24 hours of an alleged incident of abuse resulting in an automatic B violation. The violation of the regulation had a direct relationship to the health, safety or security of residents.