Failure to Timely Report Suspected Abuse Incident
Penalty
Summary
The facility failed to report an incident of potential resident abuse by a staff member in a timely manner to the Administrator. A Certified Nursing Aide (CNA) was reported by another CNA for rushing a resident during care. The incident involved a resident with severe cognitive impairment, Alzheimer's disease, depression, and total urinary and bowel incontinence, who was dependent on staff for all activities of daily living. The resident required maximum assistance for transfers and was at risk for skin breakdown. The care plan specifically indicated that staff should not rush the resident and should allow sufficient time for tasks. The incident was observed by an LPN, who saw the CNA pulling on the resident's arm during a transfer. Although a head-to-toe assessment was reportedly performed, the LPN failed to document the incident or the assessment in the clinical record, and did not take vital signs or complete a pain assessment following the event. The facility's policy required immediate reporting of suspected abuse to the Executive Director, but this was not done in a timely manner. The deficiency was identified through record review and staff interviews.