Failure to Timely Report Alleged Physical Abuse to Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy and procedure by not reporting an allegation of physical abuse involving a resident and two staff members to the State Survey Agency within the required two-hour timeframe. The incident involved a resident with Parkinsonism, muscle wasting, quadriplegia, and depression, who was admitted with the capacity to understand and make decisions. On the day of the incident, the resident expressed not wanting care from a specific CNA and later reported that both a registry RN and the CNA physically forced her into bed against her will, despite her repeated requests to wait for the next shift. The resident described the event as traumatizing and characterized the staff's actions as physical abuse, which she reported to the Administrator via text message shortly after the incident occurred. Multiple staff interviews confirmed that the resident's allegations were not reported to the required authorities within the mandated two-hour window. The resident's nurse for the following shift acknowledged being informed of the incident but did not initiate the abuse reporting process, and the Administrator, who serves as the abuse coordinator, did not direct staff to notify the ombudsman, police, or State Survey Agency as required. The facility's Director of Staff Development and other staff also recognized that the incident met the criteria for abuse and should have been reported immediately, but there was no evidence that the appropriate notifications or suspensions were carried out in accordance with facility policy. The facility's policy clearly states that all allegations of abuse must be reported immediately to the Administrator, and that law enforcement, the ombudsman, and the State Survey Agency must be notified within two hours. The policy also requires the suspension of accused employees pending investigation and mandates written reports to authorities within 24 hours. In this case, the failure to report the resident's allegation of physical abuse in a timely manner constituted a violation of both facility policy and regulatory requirements.