Failure to Report Resident's Abuse Allegation as Required by Policy
Penalty
Summary
Staff failed to follow the facility's abuse and neglect policy when a resident with severe dementia and moderately impaired cognition told a CNA and an RN that a young black male had beaten them up. The incident occurred after the resident was transferred from a Broda chair to bed using a Hoyer lift. Despite the resident's clear speech and ability to usually make themselves understood, neither the CNA nor the RN reported the allegation to the Administrator or DON as required by facility policy. The RN questioned the resident briefly but did not pursue the matter further or initiate a report, citing the resident's confusion as the reason for inaction. Interviews with other staff confirmed that the expectation was to report any such allegations immediately, regardless of the resident's cognitive status. The Administrator and DON stated that they were not informed of the allegation and that the staff involved should have reported it immediately so an investigation could begin. The facility's policy mandates prompt reporting and investigation of all abuse allegations, but this protocol was not followed in this instance.