Failure to Timely Report Alleged Physical Abuse Incident
Penalty
Summary
The facility failed to report an allegation of physical abuse to the Agency for Health Care Administration (AHCA) in a timely manner after an incident involving a resident with dementia and behavioral disturbances. The resident, who required substantial assistance for daily activities and was on 1:1 supervision due to combative behavior, was involved in an incident where a CNA was observed holding the resident's door closed, resulting in the resident's hand being caught in the door and causing bleeding. Multiple staff members, including nurses and CNAs, witnessed the event or its aftermath but did not immediately report it as potential abuse. The incident was only discovered by facility management the following day during a review of security camera footage, at which point the incident was reported to AHCA. The resident's medical record and care plans indicated significant cognitive and physical impairments, including a history of behavioral symptoms and dependence on staff for most activities of daily living. On the day of the incident, documentation and witness statements revealed that the resident became agitated, attempted to leave his room, and sustained injuries to his hand when the door was closed on him by the CNA. Despite visible injuries and the resident's distress, staff at the nurses' station did not intervene until prompted by a visitor, and there was a lack of immediate recognition or reporting of the event as abuse. Interviews with staff and review of video footage confirmed that several employees observed the CNA's actions and the resident's subsequent injury but failed to take prompt action or notify appropriate authorities as required by facility policy and federal regulations. The delay in reporting prevented timely protective measures for the resident and delayed notification to state authorities. The facility's own investigation and witness statements further corroborated that the incident was not reported until management became aware through camera review, highlighting a breakdown in the immediate reporting process for suspected abuse.