BEULAH, ND - Federal inspectors cited Knife River Care Center for failing to report a physical abuse incident within required federal timeframes after a resident's daughter was observed slapping her mother in the face.
![Knife River Care Center - Beulah, ND]
Physical Abuse Incident Goes Unreported
The August 14, 2024 complaint investigation revealed that facility staff witnessed a family member physically abusing a resident on August 10, but administrators did not notify the State Survey Agency until August 12 - well beyond the 24-hour reporting requirement established by federal regulations.
According to the inspection report, the activities director observed the resident's daughter in the room "slapping her in the face." A licensed practical nurse immediately responded, asking the daughter to leave the facility and informing her that "abuse is not tolerated at this facility."
The resident affected by this incident was documented as having severely impaired cognition, making her particularly vulnerable to abuse and unable to advocate for herself or report the incident.
Federal Reporting Requirements Violated
Federal regulations require nursing homes to report abuse incidents to state authorities within 24 hours, or within 2 hours if the incident resulted in serious bodily injury. These strict timeframes ensure rapid response to protect vulnerable residents and allow authorities to investigate while evidence and witness accounts remain fresh.
The facility's own policy, revised in November 2023, clearly outlined these requirements. The policy stated that "any alleged violation(s) should be recorded and reported immediately to the facility Administrator and/or designee" and that the administrator "shall report the allegation to the State survey and certification agency within a 24-hour time period."
Despite having clear written procedures, administrative staff failed to follow protocol. The charge nurse reported the incident to administration on August 10, but administrators did not begin their investigation until August 12 and only then notified the State Survey Agency.
Medical and Safety Implications
Physical abuse in nursing home settings poses significant risks to residents' physical and psychological wellbeing. Face slapping can cause immediate injuries including bruising, cuts, and in elderly residents with fragile skin and bones, more serious trauma.
For residents with cognitive impairment, physical abuse creates additional concerns. These individuals may not understand why they are being hurt, cannot effectively communicate the abuse to staff, and may develop increased agitation, fear, or withdrawal behaviors that impact their overall health and quality of life.
The delayed reporting in this case meant that protective measures were not immediately implemented through proper channels. While facility staff did ask the family member to leave, formal investigations and legal protections were delayed by two full days.
Facility Response and Corrective Actions
Following the inspection, Knife River Care Center implemented several corrective measures to address the reporting failure. The facility convened an interdisciplinary team to develop interventions for resident care and safety, and medical providers were notified to ensure appropriate follow-up care for the affected resident.
The facility contacted local police and the Women's Action Resource Center (WARC) for additional support and resources. A no trespassing order was initiated to prevent the abusive family member from returning to the facility.
State ombudsman representatives and other resident advocates were notified of the incident and the facility's response actions. The facility also conducted comprehensive education for all management staff regarding abuse policies, proper reporting timeframes, and response protocols for future allegations.
Industry Standards and Best Practices
Nursing homes are required to maintain comprehensive abuse prevention programs that include immediate reporting, thorough investigations, and protective measures for victims. Staff at all levels must understand their legal obligations to report suspected abuse without delay.
Best practices include training all employees to recognize signs of abuse, establishing clear reporting chains of command, and ensuring 24/7 access to administrative staff who can make required notifications to authorities.
The facility should have immediately documented the incident, notified administration, contacted the State Survey Agency within 24 hours, and implemented protective measures to ensure the resident's safety while a formal investigation proceeded.
Regulatory Context and Enforcement
This violation falls under federal tag F609, which requires timely reporting of suspected abuse, neglect, or theft. The Centers for Medicare & Medicaid Services established these requirements to ensure rapid response to protect nursing home residents who depend on facilities for their safety and wellbeing.
The inspection determined this represented "minimal harm or potential for actual harm" affecting few residents, indicating that while the reporting delay was serious, immediate physical consequences were limited due to staff intervention.
However, federal regulators noted this citation as "past non-compliance," meaning the facility had already implemented corrective actions by the time of the formal inspection, demonstrating recognition of the violation's seriousness.
Implications for Resident Safety
This incident highlights the critical importance of proper reporting procedures in nursing home settings. When abuse occurs, immediate notification allows authorities to investigate promptly, implement protective measures, and prevent potential reoccurrence.
Delayed reporting can compromise investigations, limit available evidence, and potentially expose other residents to risk if systemic problems exist. The strict federal timeframes recognize that nursing home residents represent a particularly vulnerable population requiring enhanced protections.
For families and residents, this case demonstrates the importance of understanding facility policies and knowing that federal law requires immediate reporting of any abuse incidents. Residents and families should be aware of their rights to contact state authorities directly if they have concerns about facility response to abuse allegations.
The full inspection report and facility response plans are available through the state survey agency for those seeking additional details about this incident and the corrective measures implemented.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Knife River Care Center from 2024-08-14 including all violations, facility responses, and corrective action plans.
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