Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to follow its Abuse Prevention Policy by not reporting an allegation of staff-to-resident physical abuse to the State Agency within the required two-hour timeframe. A resident with severely impaired cognitive skills and multiple medical diagnoses, including hypertensive heart disease with heart failure and rheumatoid arthritis, was observed by two LVNs to have discoloration and redness on the right forearm. The resident indicated that a CNA had grabbed their arm during a transfer, causing pain and visible marks. Both LVNs noted the resident appeared upset and frustrated, and one LVN confirmed the discoloration was not present earlier that same morning. The incident was reported by the LVN to the DON on the same day it occurred, and the DON acknowledged that the situation constituted a possible case of physical abuse, which should have been reported to the State Agency within two hours according to facility policy. However, the allegation was not reported until two days later. The facility's policy, reviewed by surveyors, clearly states that all allegations of abuse must be reported within the federal requirement timeframe, which was not adhered to in this case.