Failure to Report Alleged Staff Misconduct to State Agency
Penalty
Summary
The facility failed to report an allegation of staff misconduct to the State Agency as required. A resident with a history of stroke, atrial fibrillation, coronary artery disease, heart failure, thyroid disorder, and sleep apnea, who required substantial assistance with activities of daily living and was cognitively intact, reported that a night shift CNA was rude, spilled a bedpan on her bed, denied the incident, and placed her call light out of reach. The resident also reported that the CNA told her she was using her call light too much and requested that this staff member not be allowed back in her room. The incident was witnessed by the resident's son, who corroborated the resident's account and added that the CNA called his mother 'crazy' and dismissed her concerns. The Director of Nursing (DON) conducted an internal investigation, which included speaking with the resident, her son, and the staff member involved. The DON provided education to the CNA regarding resident rights, infection control, and communication, and instructed her to stay out of the resident's room. However, the DON did not report the allegation to the State Agency, as required by regulation. The previous administrator, who was the Abuse Coordinator at the time, stated she was not fully informed of the incident and would have reported it had she known the full details. Other facility staff, including the Assistant Director of Nursing, were unaware that the incident had not been reported and assumed proper procedures had been followed. The facility was unable to provide a policy regarding the reporting of such incidents during the survey, and corporate staff did not supply the requested policies in a timely manner. The failure to report the allegation of staff misconduct to the State Agency constituted a deficiency in the facility's abuse reporting procedures.