Failure to Immediately Report Witnessed Abuse
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to immediately report an incident of physical abuse witnessed during care of a resident with severe cognitive impairment. The facility's policy required that any suspected abuse be reported immediately to the administrator or designee. During the night shift, CNA #1 observed CNA #2 respond to a combative resident by threatening retaliation and then forcibly grabbing the resident's wrist and slapping the back of the resident's hand twice. The resident, who had diagnoses including dementia, anxiety disorder, and major depressive disorder, yelled out in response to the slaps. Despite witnessing the incident, CNA #1 did not report it to the nurse on duty as required by facility policy. Instead, CNA #1 completed her shift, went home, and only returned to the facility approximately two hours later to report the incident to the nurse. The delay in reporting was confirmed through interviews and review of written statements, and the Director of Nursing acknowledged that the immediate reporting requirement was not followed.