Failure to Immediately Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident with moderately impaired cognition and a recent gastrointestinal surgery was reported to the State Agency immediately, as required. On the evening of the incident, the resident reported to a nursing assistant that a registered nurse had put hands on her neck and pushed her back into bed, causing the resident to feel shocked and afraid, though not physically harmed. The nursing assistant told the resident he would report the incident to someone higher, but the registered nurse, after being informed of the allegation, returned to the resident's room to discuss the situation instead of reporting it to the administrator or DON. The delay in reporting was confirmed when the DON stated that the allegation was only brought to her attention several days later by a social worker, at which point an investigation was initiated. The facility's policy required immediate reporting of any abuse allegations to the administrator, but this protocol was not followed. No formal re-education was provided to staff regarding the importance of immediate reporting, and the registered nurse continued to work with the resident after the incident.