Failure to Timely Report Witnessed Abuse Incident
Penalty
Summary
Nursing staff failed to immediately report a witnessed incident of verbal and physical abuse involving a resident with moderate cognitive impairment, right below the knee amputation, anxiety, long-term pain, and peripheral vascular disease. The incident occurred when a registered nurse, while providing care, grabbed the resident's arm, shoved them, and used profane language after the resident did not turn quickly enough during incontinent care. The abuse was witnessed by a nursing assistant, who did not report the incident to other staff or the State Agency until several hours later, outside the required two-hour reporting window outlined in facility policy. The Director of Nursing Services confirmed that the report to the State Agency was not made until after they were informed of the incident, which was not in accordance with the facility's policy requiring immediate reporting of abuse allegations. The failure to promptly report the witnessed abuse resulted in non-compliance with mandated reporting requirements and placed the resident at risk for unidentified and potentially ongoing abuse.