Failure to Immediately Report and Intervene in Observed Resident Abuse
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) failed to immediately report an observed incident of abuse involving a resident with severe cognitive impairment. The incident involved a Licensed Practical Nurse (LPN) who placed his hands over the resident's mouth and nose, using a paper towel to pinch the nose, in an attempt to force the resident to swallow medication. The resident, who had diagnoses including acute respiratory failure with hypoxia, dementia, cerebrovascular disease, and pain, was observed struggling, turning red in the face, and pushing their head from side to side during the incident. The CNA, after witnessing this, initially attempted to inform another LPN, who declined to get involved, and then delayed reporting the incident to facility administration. The facility's policy required that all alleged violations involving abuse, neglect, or mistreatment be reported immediately, but no later than two hours after the allegation is made, to the administrator or other officials. In this case, the CNA did not report the incident to the Director of Nursing (DON) until several hours after the event, and the abuse was not reported to the State Agency until later that day. During this time, the LPN involved continued to work his shift without direct monitoring or oversight. Interviews with staff confirmed that the CNA did not understand the importance of immediate reporting and that other staff members did not intervene or ensure the report was made promptly. The delay in reporting and failure to protect the resident from further potential harm constituted a violation of the facility's abuse prevention policy. The deficiency was substantiated through interviews, record reviews, and examination of the facility's own investigative documentation. The incident affected one resident who was sampled for abuse, and the failure to report and intervene as required placed the resident at risk.