Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, or no later than two hours after the allegation was made. Specifically, a resident reported an incident of verbal abuse by a Certified Nurse Aide (CNA) to another CNA on February 5, 2023. However, this allegation was not communicated to the facility administration until February 6, 2023, and was not reported to the New York State Department of Health until February 8, 2023. The facility's policy mandates that any knowledge or suspicion of abuse should be reported immediately to the Shift Supervisor/Charge Nurse/Manager, who would then notify the Administrator and Director of Nursing, and subsequently report to the designated State agency within two hours. The resident involved was admitted with unspecified diagnoses and was assessed to have no cognitive impairment, being able to understand and communicate effectively. The facility's investigation revealed that the resident felt intimidated when CNA #3 yelled at them, an incident witnessed by CNA #4. Although the accused CNA did not intend to upset the resident, their approach was inappropriate as per the resident's care plan. The failure to report the incident promptly was partly due to CNA #4's perception that the accused's behavior was not abusive, as they were typically loud and gruff. Additionally, the Administrator, who was new to the position, acknowledged a lack of clarity regarding their reporting responsibilities at the time of the incident.
Plan Of Correction
Plan of Correction: Approved April 25, 2025 Resident #115 was discharged from the facility on (MONTH) 24, 2023. Certified Nursing Aides #3 and #4 are no longer employed at the facility. All residents have the potential to be affected by this deficient practice. All staff will be re-educated on their obligation to report all instances of actual or perceived abuse immediately to the supervisor and/or administrator in order to initiate investigation and allow for reporting within two hours to the appropriate state agencies. The Abuse – Prevention and Management Policy was reviewed with no changes or modifications determined to be necessary at this time. An Incident/Event Report Checklist is currently being completed for each incident by the Administrator to ensure that any incident involving an allegation of abuse is reported within the two-hour timeframe to the appropriate individual and state agencies. A weekly audit of Incident/Event Report Checklists completed for the applicable week will be done by the Administrator or designee in order to verify that all incidents involving an allegation of abuse were reported timely and to the appropriate individual and state agencies. Results of the weekly audit will be reported to the Quality Assurance Performance Improvement committee monthly and will continue in frequency based on the determination of the committee. At a minimum, monthly audits will continue until compliance is maintained for a period of 3 consecutive months. Any identified non-compliance will be addressed through staff re-education and/or formal disciplinary action. The Administrator or Designee is responsible for this plan of correction.