Failure to Timely Report Alleged Resident Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported in a timely manner for one resident. According to facility policy, any suspicion or incident of abuse, neglect, mistreatment, or misappropriation of property must be reported immediately to designated authorities within the facility. However, an incident occurred during a mechanical lift transfer in which a nursing assistant was observed to physically abuse a resident by pulling the resident's fingers off the lift, bending them backwards, and subsequently punching and pinching the resident. Another staff member witnessed the abuse, instructed the perpetrator to stop, and was told to remain silent. The witness did not report the incident to a nurse before leaving the facility at the end of the shift, resulting in a delay in notification. The incident was not discovered until the following day when the DON received a call regarding the allegation of abuse. The resident involved had severe cognitive impairment, dementia, a tracheostomy, and diabetes, and was unable to advocate for themselves. Facility leadership acknowledged that the delay in reporting did not comply with their policy, which requires immediate reporting of suspected abuse. The deficiency was identified through review of facility policy, clinical records, facility documents, and staff interviews.