Failure to Timely Report and Intervene in Suspected Abuse Incident
Penalty
Summary
Staff failed to immediately report an alleged violation involving abuse and neglect, as required by facility policy and federal regulations. On the morning of the incident, a certified nursing assistant (CNA) was overheard by other CNAs threatening to use pepper spray on a resident during a verbal altercation. Despite hearing this threat, the other CNAs did not report it to the facility Administrator or other appropriate authorities. Several hours later, the same CNA engaged in a further verbal altercation with the resident, which escalated to the CNA spraying the resident with pepper spray. The incident was not reported to the Administrator until after it had occurred, and the Administrator was unaware of the earlier threat that could have prompted preventive action. The resident involved was a male with diagnoses including bipolar disorder, schizophrenia, and spinal stenosis, and had a history of behavioral symptoms such as yelling, cursing, and physical aggression. On the day of the incident, the resident was under one-to-one supervision due to previous behaviors. Multiple staff, including CNAs and a housekeeper, witnessed the escalating situation and the use of pepper spray, but did not intervene or report the initial threat. The resident experienced burning sensations and was sent to the hospital for evaluation, where no injuries were documented. Interviews with staff revealed that several individuals were aware of the threat made by the CNA but assumed others would report it or did not know how to respond. The Administrator and Assistant Director of Nursing (ADON) confirmed they were not informed of the threat prior to the incident. Facility policy required immediate reporting of suspected abuse to the Administrator or designated supervisor, but this protocol was not followed, resulting in a delay in addressing the situation and potential risk to the resident.