Failure to Timely Report Alleged Abuse and Remove Accused Staff
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse within the required two-hour timeframe. A Certified Nurse Aide (CNA) witnessed a Nurse Aide in Training (NAIT) cover a resident's mouth with her hand, tap the resident's mouth, and tell the resident to "shut up." This incident occurred on 08/22/25, but was not reported to facility management until 08/29/25, seven days later. During this period, the accused NAIT continued to work in the unit, potentially exposing other residents to risk. The CNA who witnessed the incident did not immediately report it, stating she was unsure of what to do, and only informed a Registered Nurse (RN) after several days had passed. The RN, upon learning of the incident, immediately reported it to the Unit Manager, who then notified the Director of Nursing (DON). The DON confirmed that the facility did not become aware of the allegation until seven days after the event and that the initial report to the State Agency was also delayed. Timesheet records confirmed that the accused NAIT continued to work during the period between the incident and the report. The delay in reporting resulted in the identification of Immediate Jeopardy by surveyors.
Removal Plan
- R #4 was assessed by using a Trauma Informed Assessment.
- Tele-visit with Psych provider, agreed with Trauma Informed Assessment for R #4, no immediate trauma and will continue psych caseload.
- Safe survey for all facility residents was initiated with no immediate concerns verbalized. Residents verbalized desire to continue living in facility and feel safe.
- Referral for additional spiritual services for support within the community for R #4 via hospice team.
- R #4's Care Plan updated for trauma-informed care.
- All staff were re-educated on abuse and neglect definition, signs and symptoms of abuse and reporting and when to report, zero-tolerance expectation, resident rights, and mandatory reporting within 2 hours.
- Staff training was conducted for all facility staff.