Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe for a resident who had sustained skin tears during an altercation with a Certified Nursing Assistant (CNA). The incident occurred when the resident, who had a history of cognitive and behavioral issues, became combative with the CNA, resulting in the CNA grabbing the resident's arm to protect herself. The resident later alleged that the CNA's actions caused the skin tears. The incident was first reported internally at 10:30 a.m. by the CNA involved, but the Director of Nursing (DON) and the Nursing Home Administrator (NHA) were not informed until approximately 2:30 p.m., leading to a delay in the official reporting of the abuse allegation to the authorities. The facility's policy mandates that such allegations be reported within two hours, but the report was not made until 4:30 p.m., four hours after the incident was initially reported internally. Interviews with staff revealed a breakdown in communication and reporting procedures. The Licensed Practical Nurse (LPN) on duty did not immediately recognize the incident as an abuse allegation and failed to initiate the reporting process promptly. The DON and NHA both acknowledged that they should have been notified earlier, and the facility's training materials clearly outlined the requirement for immediate reporting of abuse allegations.
Plan Of Correction
1. The allegation related to Resident #1 was reported promptly upon notification to Administrator/Coordinator and within 2-hour timeframe. CNA was suspended immediately upon notification of allegation by Director of Nursing. Resident #1 received appropriate interventions, including emotional support and follow-up assessments. Resident #1 remained at her behavioral baseline, in no mental anguish, and participating in her normal activities. 2. Administrator/Designee interviewed all alert and oriented residents on Staff D CNA's assignment were interviewed on and all not alert and oriented residents had skin assessments completed to observe for any possible signs of. No other residents were affected. Administrator/Designee conducted staff interviews on to identify any possible concerns. No concerns identified. A comprehensive review of all incidents over the last 90 days was completed by Director of Nursing/Designee to identify any potential un-reported allegations. No new findings were identified. 3. Administrator/Designee educated all staff on Neglect and Misappropriation Reporting Policies and Procedures and completed Post-Test. All education and post-tests were completed by or prior to their next scheduled shift. Administrator/Designee to educate all new hires on Policies and Procedures and post-test completed during new-hire orientation. DON/Designee completed written coaching with Staff F, Weekend Supervisor and Staff H, RN to ensure moving forward reporting process is followed. Administrator implemented random interviews with residents, staff, and families to be conducted by different members of the Interdisciplinary Team weekly x 3 months to ensure no events go un-reported. Administrator/Designee will review completed interviews daily to determine if any concerns need to be reported. 4. Administrator/Designee will complete daily audits of all incident reports x4 weeks then 3x a week audits for 3 months or until substantial compliance is achieved. Non-compliance in the reporting process will result in corrective training and disciplinary actions. Results of audits will be taken to monthly QAPI x3 months or until substantial compliance is achieved.