Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all allegations of possible abuse were reported immediately to facility management and within two hours to the state licensing agency, as required by both facility policy and federal regulations. Specifically, a nurse aide (NA C) witnessed another aide (NA D) slap a resident during care after the resident, who has severe cognitive impairment and behavioral symptoms related to dementia, became physically aggressive. Instead of reporting the incident immediately, NA C waited until the following day to inform management, citing discomfort with reporting while still on shift with the involved staff member. The resident involved had a history of vascular dementia, polyneuropathy, and required assistance with personal care, exhibiting frequent behavioral challenges such as yelling, physical aggression, and refusal of care. The care plan for this resident included specific interventions for managing behavioral symptoms, but during the incident, the staff response escalated to physical abuse. The delay in reporting meant that the incident was not brought to the attention of the Administrator until the afternoon of the following day, and the state agency was not notified within the required two-hour window. Interviews with multiple staff members, including CNAs, RNs, the Social Services Director, the DON, and the Administrator, confirmed that facility policy and their training require immediate reporting of abuse allegations to management and notification to the state agency within two hours. Despite this, the actual practice in this case did not align with policy, resulting in a failure to protect the resident and comply with regulatory requirements for timely reporting of abuse.