Failure to Timely Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, as required. Specifically, staff members including two LVNs and two CNAs did not report a resident's allegation of abuse and neglect to the facility's Abuse Coordinator (the Administrator). The incident involved a male resident with paraplegia, major depressive disorder, insomnia, chronic pain, neurogenic bowel, and neuromuscular dysfunction of the bladder, who was cognitively intact and required partial to moderate assistance with toileting hygiene. The resident alleged that a CNA attempted to strangle or choke him after he confronted her about not being changed for several hours. Multiple staff interviews and record reviews revealed that the resident had his call light on for an extended period, called the front desk, and eventually wheeled himself to the nurse's station to seek assistance. When he found the CNA, a confrontation occurred during which the resident felt threatened by the CNA's actions, though no physical injuries were observed or documented. The incident was communicated to several staff members, including LVNs and CNAs, but none of them reported the allegation to the Abuse Coordinator or completed an incident report in a timely manner. The facility's policy required immediate verbal reporting of suspected abuse, neglect, or exploitation to the Abuse Preventionist or designee, with a two-hour reporting window for allegations involving abuse or serious bodily injury. Despite this, the staff involved did not follow the policy, resulting in a delay in reporting the resident's allegation. The deficiency was identified through interviews, record reviews, and examination of facility policies, which confirmed that the required immediate reporting did not occur as stipulated.