Failure to Immediately Report Alleged Abuse and Resident Injuries
Penalty
Summary
The facility failed to identify and immediately report an allegation of abuse involving a resident who developed bruising on her hands and wrists, reportedly as a result of a staff member holding her arms. The resident communicated the alleged abuse to several staff members, including a CNA and an LPN, during the night shift. Despite being informed, these staff members did not immediately notify the Administrator or management about the allegation. The CNA reported the resident's accusation to the LPN, who also failed to escalate the concern. Other staff members observed the bruising and heard the resident's allegations but did not report them promptly. The delay in reporting was further evidenced by interviews with staff, where it was revealed that multiple employees were aware of the resident's claims and visible injuries but did not follow the facility's policy to report such incidents immediately to the Administrator. The Director of Nursing (DON) only became aware of the situation after being notified by an RN, who had been informed by the resident's daughter. The DON then initiated the investigation and notified the Administrator, but this was not done until several hours after the initial allegations were made and observed by staff. The facility's policy required that all allegations of mistreatment, neglect, or abuse, including injuries of unknown source, be reported immediately to the Administrator and other officials as required by law. In this case, the failure of multiple staff members to report the resident's allegations and observed injuries in a timely manner constituted a breach of this policy and resulted in a deficiency related to the prompt reporting of suspected abuse.