Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident in accordance with its own policy and regulatory requirements. A certified nurse assistant (CNA) witnessed another CNA forcefully and aggressively assist a resident with dementia, chronic kidney disease, venous thromboembolism, fibromyalgia, and spinal stenosis to the commode, using excessive force and manhandling the resident. The incident occurred late at night and was not reported to the appropriate authorities within the required 24-hour timeframe. The facility's Director of Nursing acknowledged that the incident was reported late to the licensing agency, local law enforcement, and ombudsman, as the report was sent by fax several days after the event. Facility policy required a telephone report to law enforcement and written reports to the ombudsman and licensing agency within 24 hours of the incident. The delay in reporting resulted in a delayed investigation by the state agency and law enforcement. Medical assessment of the resident after the incident did not reveal any injuries or discoloration.