Failure to Report Suspected Abuse Following Resident Allegations
Penalty
Summary
The facility failed to report an incident of possible physical abuse involving one resident, as required by policy and regulation. The resident in question had a history of cognitive impairment, with documented changes in her Brief Interview for Mental Status (BIMS) scores and a diagnosis of dementia. Upon admission, the resident had significant bruising on her legs and hips, reportedly from a fall at home, and continued to have bruising during her stay. The resident and her daughter both expressed concerns to staff about rough treatment by a female staff member during overnight shifts, specifically mentioning that the resident felt the staff was rough when turning her. Staff interviews revealed that the concerns about rough handling were communicated to nursing staff, including an LPN and charge nurses. The LPN reported the resident's statements about rough treatment to the charge nurse and completed an assessment, but it was unclear if this was documented in the resident's record. The charge nurses and other staff interviewed stated that they did not recall receiving reports of rough treatment or abuse regarding this resident, and no formal report was made to the state agency. The facility's policies required that any suspected abuse be reported immediately to supervisors and the appropriate authorities, but this process was not followed in this case. Despite the facility's established policies for occurrence reporting and abuse prevention, the incident was not reported to the state agency, and there was no evidence of a formal investigation or protective measures being initiated. The administrator and DON confirmed that they were unaware of any reports of possible abuse or rough treatment involving this resident, and therefore no report was made to the state agency. This failure to report and investigate the alleged abuse constituted a deficiency in the facility's compliance with regulatory requirements for protecting residents from abuse.