Failure to Timely Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to ensure timely reporting of abuse allegations in accordance with its own policy for two residents. In both cases, staff members witnessed or were made aware of incidents involving a Certified Nurse Aide (CNA) who allegedly engaged in abusive behavior, including physical and verbal abuse, but did not immediately report these incidents to the appropriate authorities or supervisors. The CNA was allowed to continue working after the alleged incidents, potentially affecting all residents under their care. One resident, who had severe cognitive impairment due to dementia, was reportedly grabbed forcefully on the arm by the CNA, resulting in visible red marks and pain that lasted for days. The resident expressed distress immediately after the incident, and staff present at the time observed the resident's upset state and physical marks. Despite being trained to report such incidents, the staff did not immediately communicate their suspicions to the charge nurse or administration, citing reasons such as being unsure of what had happened, assuming others would report, or being in shock. Another resident, who was cognitively intact and diagnosed with Parkinson's disease, experienced verbal abuse and was subjected to a cold shower against their wishes, causing emotional distress and physical discomfort. The resident was left alone and naked in the shower room for an extended period and reported the incident to staff afterward. Again, the staff member who witnessed or was informed of the incident did not report it immediately, only disclosing the details the following day when prompted by a supervisor. Interviews confirmed that staff had received training on abuse and neglect reporting, and facility policy required immediate reporting, but this protocol was not followed in these cases.