Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to immediately report an allegation of potential physical abuse involving a resident with a history of traumatic brain injury and left-side hemiplegia. The resident, who required maximum assistance for mobility and was at risk for falls, reported to two RNs that a nurse aide had grabbed their arm during a transfer, resulting in a bruise. Both RNs observed the injury and were aware of the allegation, but neither ensured that the incident was reported to the Director of Nursing (DON) or the Administrator as required by facility policy. The nurse aide in question was not immediately removed from duty, and the incident was not promptly investigated. Facility documentation and interviews revealed that the DON was not informed of the allegation until the following day, and the required report to the state agency was not made within the mandated two-hour timeframe. The facility's policy specifies that suspected abuse must be promptly reported to management and the appropriate authorities, but this protocol was not followed. The delay in reporting and failure to initiate an immediate investigation constituted a deficiency in the facility's response to the abuse allegation.