Failure to Immediately Intervene and Report Physical Abuse by Family Member
Penalty
Summary
Facility staff failed to immediately identify and intervene in an incident of physical abuse involving a severely cognitively impaired resident who was dependent on staff for all activities of daily living. The incident occurred when the resident was struck multiple times with a belt by a family member, resulting in visible whip-like marks on the resident's thigh and abdomen and necessitating a visit to the emergency room. Multiple staff members, including a nurse and two nurse aides, heard sounds consistent with physical abuse and cries of pain coming from the resident's room but did not enter the room to intervene or protect the resident at the time of the incident. Instead, the nurse sought out the Unit Manager, and the nurse aides returned to their duties without further investigation. The staff's response was delayed, as neither the nurse nor the nurse aides immediately entered the room to stop the abuse, despite hearing distressing sounds and being aware that a family member was present. The nurse later admitted that she did not intervene because she was in shock and had never encountered a family member abusing a resident, although she acknowledged she would have acted differently if another resident had been the perpetrator. The nurse aides also did not recognize that a family member hitting a resident constituted abuse within the facility. The Unit Manager eventually entered the room, confronted the family member, and observed the physical injuries on the resident. Additionally, the facility failed to notify the state agency within the required two-hour timeframe after becoming aware of the abuse. The initial allegation report was not sent to the state agency until the following day, well beyond the mandated reporting window. The facility administrator believed that notifying the local police department fulfilled the reporting requirement, but later confirmed that the state agency was not contacted until the next day. This delay in reporting, combined with the lack of immediate intervention, constituted a failure to adhere to the facility's abuse policies and procedures.