Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported immediately, but no later than two hours after the allegation was made, as required by policy and regulation. A Certified Nurse Aide self-reported to an LPN that they had unintentionally tapped a resident's hand during a shower when the resident was combative, resulting in a reddened area and subsequent bruise. The LPN observed the injury and notified a Registered Nurse, and both the involved aides were sent to the supervisor's office. However, the incident was not reported to the Director of Nursing until the following morning, and the State Department of Health was not notified until over 30 hours after the initial allegation. The resident involved had a history of anxiety disorder, cognitive communication deficit, and insomnia, and was assessed as having moderate cognitive impairment but was able to understand and be understood. The facility's policy required immediate reporting of all abuse allegations to the Executive Director and to state authorities within two hours if abuse was involved. Despite these requirements, the delay in reporting the incident to both facility leadership and the State Survey Agency constituted a failure to follow established procedures for timely reporting of suspected abuse.