Failure to Timely Report and Respond to Alleged Resident Abuse
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 as required. Specifically, an incident occurred in which a male resident with severe cognitive impairment and a history of dementia, psychosis, restlessness, agitation, and anxiety disorder was allegedly punched in the chest by a medication aide (MA) after the resident kicked the MA. The incident was witnessed by another resident's family member, who reported it to the former Assistant Director of Nursing (ADON) four days later. The former ADON did not report the allegation to the Administrator or the abuse coordinator, nor did he initiate the required notifications or immediate suspension of the accused staff member. The facility's records indicate that the alleged abuse was not reported to the state agency until a month after the incident, when the family member reported the event to the Administrator upon seeing the MA assigned to the same unit again. During this period, the MA continued to work in the facility, including being reassigned to the unit where the incident occurred. The facility's policy required immediate reporting of suspected abuse to the Administrator and other authorities, and for any employee accused of abuse to be placed on leave with no resident contact until the investigation was complete. These procedures were not followed in this case. Interviews with the former ADON revealed that he was aware of concerns regarding the MA's behavior but did not take the necessary steps to escalate or formally report the incident. The family member who witnessed the event expressed concern about the MA's continued presence on the unit, which prompted the eventual report to the Administrator. The delay in reporting and failure to remove the accused staff member from resident contact constituted noncompliance and resulted in a period of Immediate Jeopardy.