Failure to Timely Report Alleged Abuse to Administrator
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse or neglect were reported immediately, but no later than two hours, as required by facility policy. After a resident reported to the DON that she had received a bruise from a staff member following a shower, the DON did not report this allegation to the Administrator (ADM) as required. The DON stated that the resident showed her arm and said, 'look at this bruise, she did it,' but the DON did not observe any bruising and did not follow up or report the allegation, assuming the ADM had overheard the comment. The ADM only became aware of the allegation about a week later, after the resident's responsible party (RP) reported it to a nurse, who then notified the ADM. The resident involved had a history of major depressive disorder, anxiety disorder, and impulse disorder, and was care planned for risks related to skin impairment, resistiveness to care, and potential for physical aggression. The resident's care plan included interventions such as weekly skin inspections and having two staff present during showers. Despite these interventions, the resident reported being pinched by a CNA during a shower, which was not her scheduled shower day. Multiple staff interviews confirmed that the resident made a statement about a bruise after her shower, but the initial report was not escalated according to policy. Documentation and interviews revealed that the resident's report of abuse was not communicated to the ADM until several days after the incident, delaying the initiation of an investigation. The facility's policy required immediate reporting of all alleged violations to the ADM, but this was not followed. The delay in reporting could have resulted in a failure to protect the resident from further harm and did not comply with the facility's established procedures for handling allegations of abuse.