Delayed Reporting of Alleged Physical Abuse
Penalty
Summary
The facility failed to implement its Abuse Prevention and Prohibition Program policy by not reporting an allegation of physical abuse to the State Survey Agency within the required two-hour timeframe. A resident, who had been admitted with diagnoses including type 2 diabetes mellitus, repeated falls, and respiratory failure, reported to a registered nurse that a certified nursing assistant (CNA) had handled her roughly during activities of daily living, specifically while changing her brief. The resident expressed fear of falling due to the CNA's actions and relayed the incident to her family, which was subsequently overheard by nursing staff. Documentation and interviews revealed that the incident was reported to the Assistant Administrator more than four hours after the resident initially informed staff, and the official report to the State Survey Agency was made at 2:48 p.m., despite the incident being brought to staff attention at 10:15 a.m. The Director of Nursing and other staff acknowledged the delay in reporting and confirmed that the facility's policy requires immediate reporting, but staff conducted their own investigation before notifying the appropriate authorities. The delay in reporting was also recognized by the registered nurse involved, who admitted to not reporting the allegation in a timely manner. The facility's policy, last revised in January 2025, clearly states that all allegations of abuse must be reported immediately, but no later than two hours, to the state survey agency, law enforcement, and the Ombudsman. The failure to adhere to this policy resulted in a delay in reporting the alleged abuse, which could have allowed the CNA to continue working with the resident and potentially caused further distress to the resident and her family.