Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
Staff failed to report an allegation of abuse in a timely manner for a resident with severe cognitive impairment and a history of falls. The resident, who required maximal assistance with transfers and had interventions in place for cognitive loss, was observed by a nursing assistant (NA) to be verbally abused by an LPN during the night shift. The NA witnessed the LPN expressing frustration toward the resident and placing items such as wheelchairs and a nightstand around the resident's bed, effectively blocking the sides of the bed. The NA did not immediately report the incident to the RN supervisor, and the RN supervisor only became aware of the situation hours later when the resident's roommate requested assistance. The Director of Nursing Services (DNS) and the Administrator were not notified of the allegation until several hours after the incident, at which point the State Agency was informed. Facility policy required immediate notification of administration regarding any abuse allegations, but this protocol was not followed. The delay in reporting was confirmed through staff interviews and review of facility documentation, which did not identify reasons for the failure to report promptly.