Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to immediately report an allegation of staff-to-resident abuse to the State Survey Agency, as required by regulation and facility policy. A resident with multiple diagnoses, including sepsis, seizures, bipolar disorder, and major depressive disorder, who was rarely or never understood by staff, was at risk for falls and had interventions in place for safety and engagement. On the evening in question, a CNA and an LPN witnessed another LPN repeatedly snatch a stuffed animal from the resident, refuse to return it unless the resident complied with demands, and make statements such as the toy being in 'jail' and the resident being 'bad.' These actions caused the resident to become visibly upset and agitated, prompting staff to report the incident to the unit manager immediately. Despite the immediate internal reporting, the facility did not notify the State Survey Agency of the abuse allegation until two days after the incident. Review of the facility's self-reported incidents and interviews with staff and the administrator confirmed the delay in reporting. Facility policy required that allegations of abuse and the results of investigations be reported within required timeframes, which was not followed in this case. This deficiency was identified during a complaint investigation and affected one of three residents reviewed for abuse.