Failure to Immediately Report Resident Abuse Allegation
Penalty
Summary
A deficiency occurred when staff failed to immediately report an allegation of abuse involving a resident with chronic respiratory failure and failure to thrive, who was dependent on staff for bathing and had a care plan allowing showers at her discretion. On the night in question, a certified nursing assistant (CNA) forced the resident to take a shower against her will, despite the resident's verbal protests and screams. The incident was witnessed by another CNA and a registered nurse (RN), both of whom assisted in lowering the resident into a shower chair but did not intervene further or report the incident to management at the time. The abuse was only reported several days later by another resident to the Director of Nursing (DON), prompting an investigation. Interviews confirmed that the resident had been forced to shower despite her refusal, and that staff present during the incident did not take appropriate action to stop the abuse or notify facility leadership as required by policy. The facility's policy mandates immediate reporting of all abuse allegations to the Administrator for appropriate notifications to state authorities, which did not occur in this case. The failure to report the incident promptly delayed the facility's response and investigation into the abuse. The deficiency was identified during a review of medical records, staff and resident interviews, and facility self-reported incidents, which confirmed that the required immediate reporting procedures were not followed by the staff involved.