Failure to Timely Report Alleged Abuse to Management and State Agency
Penalty
Summary
The facility failed to ensure that all allegations of possible abuse were reported immediately to management and within two hours to the Survey Agency, as required by policy. An incident occurred involving a resident with moderate dementia, anxiety, and other significant medical conditions, where a certified nurse aide (CNA) forcefully held the resident's hands across their chest after the resident struck the CNA during incontinence care. The incident was witnessed by another nurse aide (NA), who did not immediately report the event to the charge nurse or management as required. Instead, the witnessing NA discussed the incident with another NA the following night, who then advised that it should be reported. The second NA delayed reporting the incident to the charge nurse until later that day, resulting in the allegation not being reported to facility management or the state agency within the required two-hour timeframe. Interviews revealed that both NAs were unclear about the proper reporting procedures and timeframes, with one NA being new and not knowing who to report to, and the other believing it was acceptable to wait since the incident had already been delayed. Further interviews with other staff, including CNAs, LPNs, and administrative personnel, confirmed that facility policy required immediate reporting of abuse allegations to supervisors and management, and that the state must be notified within two hours. However, there was inconsistency in staff knowledge regarding the reporting process and required timeframes, contributing to the delay in reporting the incident involving the resident. The deficiency was identified through review of records, staff interviews, and facility policy.