Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to ensure that alleged violations involving abuse were reported immediately, but not later than two hours after the allegations were made, to the abuse coordinator for two residents. Staff members witnessed or were aware of incidents involving a certified nursing assistant (CNA) allegedly placing soap in a resident's eyes during a shower and physically restraining another resident by pinning him with her knee and hand during care. Despite being trained to report abuse immediately, the staff members involved did not report these incidents to the abuse coordinator as required. The residents involved had significant cognitive and physical impairments. One resident was a female with moderate cognitive impairment, depression, dementia, epilepsy, blindness in one eye, and required substantial assistance with activities of daily living. The other resident was a male with severe cognitive impairment, hemiplegia, dementia with mood disturbance, seizures, and was dependent on staff for toileting hygiene. Interviews and record reviews indicated that the residents did not report feeling unsafe, and family members did not express concerns about their care. However, staff interviews revealed that the incidents were not reported promptly due to fear of retaliation from the CNA involved and concerns related to social media threats. Multiple staff members, including nursing assistants and nurses, confirmed they were trained to report abuse immediately to the abuse coordinator, whose contact information was made available to all staff. Despite this, the delay in reporting was attributed to fear of the CNA and lack of comfort in approaching supervisory staff. The abuse coordinator was eventually notified several days after the incidents, which delayed the initiation of an investigation into the alleged abuse. The facility's policy required immediate reporting of suspected abuse, neglect, or exploitation, which was not followed in these cases.