Failure to Promptly Report Allegation of Abuse
Penalty
Summary
Facility staff failed to promptly report a resident's allegation of abuse to the facility's abuse coordinator as required by facility policy. A resident with multiple medical conditions, including moderate cognitive impairment, blindness, and recent abdominal surgery, reported that during incontinence care, a CNA held her left wrist and would not let go when asked, causing her discomfort and prompting her to swat at the CNA. The resident recognized the CNA by her voice and reported the incident to her nurse the following morning, stating she felt rushed during care. The nurse who received the allegation did not report it directly to the abuse coordinator but instead relayed the information to her supervisor, the Assistant Director of Nursing (ADON). The ADON, in turn, discussed the matter with the Director of Nursing (DON) later in the day, after the resident's Power of Attorney also reported concerns. The Assistant Administrator only became aware of the allegation after the DON received a voicemail from the resident's Power of Attorney. The initial report to authorities and the start of the investigation were delayed until the Assistant Administrator interviewed the resident and determined an allegation of mental abuse had occurred. Interviews with the involved CNAs confirmed that the resident had complained of pain and asked for her wrist to be released during care, but the CNA continued to hold her wrist. Neither the CNA nor the assisting agency CNA reported the incident or the resident's complaints at the time. The facility's policy requires immediate reporting of all abuse allegations to the Administrator, but this protocol was not followed, resulting in a delay in both internal and external reporting of the suspected abuse.