Failure to Immediately Report and Investigate Abuse Allegation
Penalty
Summary
The facility failed to ensure that staff implemented the abuse policy and procedure regarding immediate reporting, investigation, and protection following an allegation of abuse. Specifically, when a resident was found with a bruise on her right shoulder and reported being hit by a woman, nurse aides promptly informed a nurse, who then informed the Nurse Supervisor. However, the Nurse Supervisor delayed reporting the allegation to the Director of Nursing (DON) and the Administrator, as required by facility policy, which defines 'immediately' as within two hours for abuse allegations. The DON and Administrator were not made aware of the incident until informed by the surveyor, resulting in a delay in notifying the State Agency, local law enforcement, and Adult Protective Services (APS), as well as a delay in initiating an investigation. Interviews with staff revealed that the resident gave inconsistent accounts of the incident, but staff acknowledged that the policy required immediate reporting regardless of the resident's changing statements. The DON stated that she would have suspended any suspected staff and begun an investigation had she been notified in a timely manner. The Administrator confirmed that he would have reported the allegation to the appropriate authorities within the required timeframe if he had been informed. The failure to follow the established abuse reporting protocol led to a delay in protective actions and regulatory notifications for the resident involved.