Failure to Timely Report Alleged Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of abuse involving two residents, both of whom were cognitively impaired and had complex medical histories. One resident, admitted with diagnoses including spinal stenosis and chronic kidney disease, reported being touched inappropriately by another resident who had dementia, a urinary tract infection, and a history of wandering and behavioral issues. The incident occurred in the early morning hours when the resident with dementia entered the other resident's room and attempted inappropriate contact, prompting the affected resident to push her away. A Certified Nursing Assistant (CNA) discovered the situation after hearing the affected resident yelling. The CNA removed the resident with dementia from the room and informed the nurse on duty, who was on break at the time. The exact time of notification to the nurse is unclear, and the nurse's subsequent actions were not fully documented. The facility's own policy requires immediate reporting of suspected abuse to a supervisor or charge nurse, followed by notification of the Administrator or Director of Nursing (DON), regardless of the time lapse since the incident. Interviews and documentation revealed uncertainty about the timeline of events and reporting, with the CNA unable to recall specific policy details or the required reporting timeframe. The facility's investigation included staff and resident interviews, but the lack of timely and clear reporting by both the CNA and the nurse led to the identification of a deficiency in abuse reporting procedures. The incident was self-reported by the facility, and the deficiency was confirmed through record review, interviews, and policy examination.