Failure to Immediately Report and Respond to Resident Abuse Incident
Penalty
Summary
The facility failed to implement its policies and procedures for the immediate reporting of suspected abuse, neglect, or theft, as required by both facility policy and state law. On the date of the incident, four staff members, including two nurses, a nursing assistant, and a laundry attendant, forcibly carried a resident by his extremities to his room and held the door closed, preventing the resident from leaving. This action was not reported to the facility administrator or the State Survey Agency immediately, as required. Instead, the administrator was not notified of the abuse until two days after the incident, despite the policy mandating immediate reporting of all suspected cases of abuse to the administrator and appropriate authorities. The resident involved was an elderly male with diagnoses including major depressive disorder, anxiety disorder, and unspecified dementia with severe cognitive impairment, as evidenced by a BIMS score of 5. At the time of the incident, the resident exhibited behaviors such as wandering, taking items from other residents' rooms, and becoming agitated. Staff responded by physically restraining the resident, carrying him to his room without supporting his back or midsection, and holding the door closed to prevent his exit. The incident was only fully discovered when the DON reviewed video footage two days later, revealing the extent of the staff's actions. Interviews with staff indicated that the decision to forcibly carry and seclude the resident was made collectively, and that the DON and administrator were not fully informed of the severity of the incident at the time it occurred. Staff members demonstrated varying levels of understanding regarding what constitutes abuse, restraint, and seclusion, and some expressed discomfort with how the situation was handled. The delay in reporting and the lack of immediate notification to the administrator and state authorities constituted a failure to follow established abuse reporting protocols, resulting in the identification of Immediate Jeopardy.