Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report allegations of abuse to the administrator immediately and to the state agency within the required 2-hour timeframe for two residents. In the first case, a resident with diabetes, hemiplegia, anemia, and anxiety alleged that a CNA hurt her arm and abused her during a transfer. The CNA who witnessed the allegation did not report it to other staff, believing the accused CNA was not rough with residents. The LPN documented the resident's statement and performed a skin assessment, then notified the DON. However, there was no documentation in the resident's progress notes about the abuse allegation, and the DON did not report the incident to the state agency, instead documenting a 'soft file' and initiating an internal investigation the following day. In the second case, a resident with chronic pain, cancer, and a fractured pelvis reported that a CNA intentionally dropped her legs onto the bed and made inappropriate comments, which the resident perceived as abusive and intentional. The resident reported the incident to the DON, who stated that the initial report was about unmet needs and staff attitude, not abuse. The resident later reported the incident to the administrator, who delayed reporting to the state agency because the staff member's identity was unknown. The abuse investigation was not started until several days after the initial report, and the resident continued to be assigned to the same CNA despite her request for a change. In both cases, the facility's documentation did not reflect timely reporting of the abuse allegations to the state agency as required by federal and state regulations. Staff interviews revealed a lack of understanding of the definition of abuse and the facility's abuse reporting policy. The facility's abuse prevention program requires immediate reporting of suspected abuse, but this protocol was not followed in these instances.