Failure to Report Abuse Timely Resulting in Delayed Treatment
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of possible abuse, resulting in pain and delayed treatment for a resident with a dislocated shoulder. The facility's abuse policy required staff to report any suspicion of abuse immediately to their supervisor. However, a witness statement revealed that a nurse aide observed another aide forcefully move a resident's arm, causing a dislocated shoulder, but did not report the incident until questioned six days later. This delay in reporting led to a delay in care and treatment for the resident. The resident involved was cognitively impaired and dependent on staff for all daily care needs. Nursing notes indicated that the resident exhibited increased behaviors and requested pain relief. Subsequent notes documented bruising and pain in the resident's upper arm, leading to an x-ray that confirmed a dislocated shoulder. The facility's investigation determined that the forceful movement by the nurse aide caused the injury, and the failure to report the incident promptly resulted in a delay in addressing the resident's pain and injury.
Plan Of Correction
1. Nurse Aid 1 failed to report observed abuse in a timely manner and was suspended pending completion of investigation. Employee was terminated upon completion of investigation when determination was made that she reported the resident complaint of pain but not the witnessed abuse. 11/26/2024 2. Facility completed on the spot education related to Reporting Requirements F607 and FCMC policy on reporting suspected or witnessed abuse to supervisor immediately. Education completed on 11/26/2024. 3. Completed Virtual In-Service training on F607 Reporting Requirements. Staff not able to attend in person were required to watch the recorded session and complete a post test in HealthStream. Virtual Training completed 11/26/24. HealthStream Education completed 12/4/24. 4. Directed In-Service Training for all staff is contracted to be completed on Friday 12/20/24. Training will include F607 42 CFR §483.12(b)(1)-(5)(ii)(iii) Develop/Implement Abuse/Neglect Policies - timely reporting of abuse. The training will include: Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting/response. 5. Attendance to the Directed In service training on F607 will be monitored by the administrator and compliance will be reported to the Quality Assurance and Performance Improvement committee by email.