Failure to Report Suspicion of Abuse for Cognitively Impaired Resident
Penalty
Summary
A staff member failed to report a suspicion of abuse involving a resident with severe cognitive impairment. The incident occurred when an LPN was unable to administer medication to the resident, who was combative and refused the medication. The LPN informed an RN of the situation, who, along with a QMA, took over the medication administration. The QMA and RN entered the resident's room, closed the door, and the resident was heard yelling that she did not want the medication. Afterward, the QMA reported that they were able to get some medication into the resident, despite her fighting and spitting it out. The LPN did not witness the interaction but did not report the incident to facility leadership. The facility's abuse policy required any staff member with a suspicion of abuse or mistreatment to immediately notify the Executive Director. However, the LPN did not report the incident, and facility leadership, including the Regional President, Regional Clinical Director, and DON, were unaware of the event until the survey interview. This failure to report delayed the initiation of an investigation and notification to the appropriate agencies, as required by facility policy.