Failure to Immediately Report Alleged Abuse
Penalty
Summary
Staff failed to implement the facility's abuse policies and procedures when an accusation of abuse was made by a resident. The facility's policy requires that any employee who suspects an alleged violation must immediately notify the executive director or designee. A resident with a history of stroke, dementia, and depression, who was totally dependent for all activities of daily living and had moderate cognitive impairment, accused a CNA of wrapping a call light cord around their neck. The accusation was documented in the progress notes, but facility administration was not notified until the following afternoon, significantly delaying the required immediate reporting and investigation of the alleged abuse. The DON confirmed during an interview that she was not made aware of the accusation until the next day, and acknowledged that the nurse who first heard the allegation should have reported it to administration immediately, as required by policy and to ensure timely reporting to the state agency.