Failure to Timely Report Suspected Abuse and Facial Injuries
Penalty
Summary
Facility staff failed to report suspected abuse involving a resident who was found with multiple facial bruises. The resident, who had diagnoses including anemia, generalized muscle weakness, depression, and lacked decision-making capacity, required substantial assistance with daily activities. On the morning of the incident, a CNA discovered the resident with red and purple bruises on her face and reported that the resident stated in Spanish that she had been hit. The CNA relayed this information to an RN. Earlier, another CNA had witnessed the resident expressing fear and alleging that a male staff member had hurt her, and later observed the same staff member handling the resident roughly and covering her face with a sheet. Despite these observations and allegations, the initial reports to nursing staff did not result in immediate action or escalation as required by facility policy. Interviews with staff revealed confusion and lack of follow-through regarding mandated reporting procedures. One CNA admitted uncertainty about what to do after her initial report was not acted upon, and the RN on duty did not seek translation services to better understand the resident's statements. The facility's policy requires immediate reporting of suspected abuse to the DON and appropriate authorities, but this process was not followed, resulting in a delay that hindered the ability of regulatory authorities to conduct a timely and effective investigation.