Failure to Timely Report Allegation of Rough Care and Potential Abuse
Penalty
Summary
The facility failed to report an allegation of rough care and possible abuse involving a resident, as required by federal and state regulations. The incident involved a cognitively intact female resident who required maximum assistance with transfers and was being assisted by an agency CNA. The resident's family reported to staff that the CNA had provided rough care during toileting, specifically stating that the CNA pushed the resident down onto the toilet and wiped her roughly, which left the resident visibly upset. The family initially reported the incident to another CNA (who was also the facility scheduler), who then informed the DON. The DON did not speak directly to the resident and did not report the incident to the Administrator or the state survey agency, as required by policy and regulation. The DON interpreted the family's complaint as an issue of rudeness and improper use of a gait belt, rather than as a potential abuse allegation. The DON removed the CNA from caring for the resident but did not initiate a formal report or investigation as required. The CNA involved was allowed to continue working in the facility for at least one additional day before being sent home. The incident was not documented in the facility's self-reported incidents system, and there was no evidence that the Administrator was informed until surveyors intervened and began asking questions. Interviews with staff and the Administrator revealed confusion and inconsistency regarding what was reported and how it was handled. The Administrator only became aware of the incident after surveyor intervention and stated that she would have expected the DON to report the incident if it had been described as abuse. The facility's abuse policy requires immediate reporting of all allegations of abuse, neglect, exploitation, or misappropriation of resident property, but this policy was not followed in this case. The failure to report the allegation in a timely manner constituted a deficiency in the facility's abuse reporting procedures.