Failure to Immediately Report Alleged Abuse to Administrator
Penalty
Summary
Facility staff failed to immediately report an allegation of abuse involving a resident to the administrator as required by facility policy. On the date of the incident, two residents were involved in an altercation, and a CNA intervened. Subsequently, one resident alleged that the CNA hit him in the face. The CNA denied the allegation and stated that the incident was reported to the nurse. However, interviews and record reviews revealed that the administrator was not informed of the allegation until two days later, despite the facility's policy requiring immediate reporting of any suspected abuse to the administrator or, in their absence, the DON. Multiple staff members, including the charge nurse, social service director, and nurse supervisor, confirmed that they either did not report the incident immediately or were unaware of the physical abuse allegation until after the fact. The initial incident report documented that the CNA made contact with the resident, but an addendum later concluded the allegation was unsubstantiated. Both initial reports were faxed to the state health department two days after the incident. The facility's abuse prevention policy clearly outlines the requirement for immediate reporting of any abuse allegations, which was not followed in this case.