Failure to Timely Report Allegation of Staff-to-Resident Abuse
Penalty
Summary
A facility failed to report an allegation of staff-to-resident abuse to the State Survey Agency (SSA) and the Ombudsman within the required two-hour timeframe. The incident involved a resident with multiple diagnoses, including dementia, diabetes, anxiety, osteoarthritis, and chronic kidney disease, who had severely impaired cognition and required significant assistance with daily activities. The resident experienced an unwitnessed fall, resulting in a forehead laceration and bilateral elbow skin tears, and was subsequently transferred to a general acute care hospital for evaluation and treatment. Following the resident's return to the facility, it was discovered during the investigation that a Certified Nurse Assistant (CNA) had overheard the resident say, "you pushed me," in Spanish, directed at the CNA who found her after the fall. This information was initially communicated by the CNA to a Licensed Vocational Nurse (LVN) on the night of the incident, but the LVN misunderstood the statement and did not recognize it as an abuse allegation. The next day, the CNA repeated the statement to the LVN and a Registered Nurse (RN), at which point the allegation was reported to the facility Administrator and Director of Nursing (DON). The facility's policy required immediate reporting of abuse allegations to the SSA, Ombudsman, and other authorities within two hours if the allegation involved abuse or resulted in serious bodily injury. However, due to miscommunication and misunderstanding between staff members, the abuse allegation was not reported until the following day, well beyond the required timeframe. This delay was confirmed through interviews with the involved staff and review of facility documentation.