Failure to Timely Report Alleged Abuse and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately to the abuse coordinator and within the required two-hour timeframe to the administrator and state authorities. In one instance, a staff member witnessed a certified nursing assistant verbally and physically abuse a male resident with traumatic brain injury, dementia, and other cognitive impairments. The staff member did not report the incident immediately, only disclosing it during an unrelated investigation approximately 1.5 weeks later. The abuse coordinator became aware of the incident during staff interviews, and the administrator did not report the new allegation to the state as a separate event. In another case, a licensed vocational nurse failed to report an allegation of abuse involving two residents engaged in a physical altercation. The nurse documented the incident but did not notify the administrator or director of nursing as required. The director of nursing only became aware of the incident upon reviewing progress notes the following day. The nurse involved stated she was not present during the incident and did not recall being trained to report abuse immediately to the administrator. A third incident involved a delay in reporting a resident-to-resident altercation where one resident scratched and pulled another resident's hair, resulting in a visible injury. The administrator was not informed of the incident until the following day, after the resident reported it and showed the injury. The administrator acknowledged that the allegation was reported late and that all abuse allegations are required to be reported to state agencies within two hours of the incident. These failures were identified through observations, interviews, and record reviews, and were found to place residents at risk of abuse, physical harm, mental anguish, and emotional distress.