Failure to Timely Report Alleged Abuse to Administration and Authorities
Penalty
Summary
The facility failed to ensure that staff reported allegations of staff-to-resident abuse to administration within the required two-hour timeframe for two residents. According to facility policy, all alleged violations involving abuse or resulting in serious bodily injury must be reported immediately, but not later than two hours after the incident. In the first case, a resident with moderate cognitive impairment and multiple chronic conditions reported to a nurse that two CNAs had spoken to them in a threatening and disrespectful manner, delayed their pain medication, treated them roughly, and caused bruising. The nurse who received this report during the night shift did not immediately notify the administration, instead waiting until later in the morning when the Administrator and DON arrived. The incident was not reported to the state agency until several hours after the initial disclosure. In the second case, another resident with moderate cognitive impairment and significant care needs was involved in an allegation of verbal abuse by a CNA. The allegation was initially communicated by a family member to staff, and subsequently relayed through several staff members before reaching the Administrator and DON. Documentation and interviews revealed that the initial report of the incident was delayed, as staff who were made aware of the allegation during or shortly after their shift did not immediately escalate the report to administration. The DON confirmed that the report to the state agency was not made within the required timeframe, and that staff failed to follow the facility's policy for immediate reporting of abuse allegations. Interviews with staff, including nurses and CNAs, confirmed that there was confusion and delay in reporting both incidents. The DON and Administrator both stated that they expect staff to report any allegations or suspicions of abuse immediately, regardless of the perceived severity. However, in both cases, the required immediate notification to administration and timely reporting to the state agency did not occur, resulting in noncompliance with facility policy and regulatory requirements.