Failure to Timely Report and Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to follow its policy regarding the timely reporting and investigation of an alleged staff-to-resident abuse incident. A resident with severe cognitive impairment and significant physical disabilities was the subject of an allegation that a CNA was rough during ADL care and pushed the resident from the bed. The allegation was initially reported by the resident's roommate, who stated she informed the nursing staff, but observed that the CNA continued to work on the same floor throughout the week. Interviews with staff confirmed that the CNA was separated from the residents involved but was not suspended and continued working in the facility. Documentation review revealed that the incident was not reported to all required agencies, including the district office, Ombudsman, physician, family, and police, as mandated by facility policy. The SBAR documentation completed by the RN did not fully reflect the details of the allegation as reported by the resident, and the investigation findings were not submitted within the required five-day period. The DON confirmed that all abuse allegations should be reported and investigated according to policy, but there was no evidence that this was done in this case. The facility's written policy requires immediate reporting of abuse allegations within two hours if abuse or serious bodily injury is involved, and a written report of the investigation findings within five working days. In this instance, the facility did not adhere to these requirements, resulting in a delay in the Department of Public Health's onsite inspection and potentially delaying the prevention of further abuse for the resident involved.