Failure to Timely Report Alleged Abuse to Administration and State Agency
Penalty
Summary
The facility failed to ensure that an allegation of potential abuse involving a resident was reported in a timely manner to both the administrator and the State agency, as required by policy. The incident involved a nursing assistant (NA) who was observed by another NA to have handled a resident roughly and to have been verbally aggressive. The observing NA reported that the alleged perpetrator grabbed the resident's upper arms aggressively and, after the resident attempted to bite, pushed the resident's arm to their mouth and told them to bite themselves. The incident occurred in the presence of a unit manager (RN), but the observing NA did not immediately report the abuse to the RN or complete the required documentation at that time. Instead, the NA attempted to inform an LPN, who did not follow up or ensure the report was escalated, assuming the matter had been addressed. The DON was not informed of the incident until the following afternoon, and the administrator was updated even later. The facility's policy required that all staff report suspected abuse immediately up the chain of command and that the State agency be notified within two hours of suspicion. However, the report to the State agency was not made until nearly a full day after the incident. Interviews with staff confirmed a lack of immediate reporting and confusion about the reporting process, resulting in a significant delay in both internal and external notification of the abuse allegation.