Failure to Timely Report Alleged Abuse and Delay in Investigation
Penalty
Summary
A deficiency occurred when the facility failed to report an allegation of abuse involving a resident with severe dementia and Alzheimer's Disease, who was non-communicative and dependent on staff for all activities of daily living. The incident involved two CNAs who tied the resident's shirt sleeves together to prevent her from scratching and pinching during care. The resident was left unattended with her sleeves tied for approximately an hour, and the incident was not immediately reported to the Abuse Coordinator or the State Survey Agency as required by regulation. The incident was discovered by oncoming CNAs at the start of their shift, who found the resident unable to move her arms due to her sleeves being tied together. The nurse on duty was notified, and the sleeves were untied. However, the nurse did not report the incident to the Director of Nursing or the Abuse Coordinator, citing being busy with other duties. The CNAs who discovered the incident also did not immediately escalate the report beyond notifying the nurse, assuming the nurse would handle the reporting process. It was only after several hours that one of the CNAs contacted the Director of Nursing directly. A review of time records showed that the CNAs involved in restraining the resident continued to work subsequent shifts after the incident, as the delay in reporting prevented immediate administrative action. The facility's policy required immediate reporting of abuse allegations, but the actual reporting to the State Agency occurred approximately 22 hours after the incident. The failure to promptly report the incident resulted in a delay in investigation and allowed the alleged perpetrators to continue working with the resident.