Failure to Timely Report Allegation of Resident-to-Resident Physical Abuse
Penalty
Summary
Facility staff failed to report an allegation of physical abuse in a timely manner after a resident, who had intact cognitive functioning and a history of anxiety disorder, multiple sclerosis, and chronic pain syndrome, reported being hit on the legs by her roommate. The incident was first disclosed by the resident to a Certified Nurse Assistant (CNA), who then informed a Licensed Vocational Nurse (LVN), and subsequently a Registered Nurse (RN). Despite the resident's clear statements to multiple staff members on the night of the incident, the allegation was not immediately reported to the facility's Administrator or to the required authorities as outlined in the facility's abuse reporting policy. Interviews with staff confirmed that the CNA, LVN, and RN were all made aware of the resident's claim that her roommate had hit her legs. The RN acknowledged that the resident's statement constituted an allegation of physical abuse and should have been reported immediately to the Administrator, who also served as the Abuse Coordinator. The Director of Nursing (DON) and the Administrator both stated that the facility's policy required immediate reporting of suspected abuse, defined as within two hours, but this protocol was not followed. Instead, the staff delayed reporting, and the investigation was not initiated until several days later when the resident informed the Administrator directly. Facility records and interviews revealed that staff did not report the allegation because they believed the accused resident was not capable of such behavior. This decision was made despite the facility's policy, which mandates reporting all suspicions of abuse regardless of staff assumptions. The failure to report the incident promptly resulted in a delay in investigation and intervention, as confirmed by the facility's own documentation and staff statements.