Failure to Timely Report Suspected Abuse Following Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to timely report an allegation of abuse involving a resident with severe cognitive impairment and significant care needs. The resident, diagnosed with dementia and dependent on staff for personal hygiene and mobility, was found to have a swollen and bruised left hand during morning care. Subsequent assessment and x-ray revealed a minimally displaced distal ulnar fracture. The incident took place during incontinence care provided by two nurse aides, one of whom was observed to have grabbed the resident's wrist and shoulder and pulled the resident toward her, causing the resident to grimace. Interviews and documentation indicated that one nurse aide was in a hurry and became frustrated during care, using excessive force to turn the resident, who was not following commands and was slightly resistive. The other aide present during the incident acknowledged that care should have been paused and reapproached later, and admitted that the nurse should have been notified immediately when the incident occurred. However, the incident was not reported to nursing staff at the time, resulting in a delay in addressing the potential abuse. Facility policy required immediate reporting of any allegations of abuse, including the willful infliction of injury or pain. Despite this, the staff involved did not follow protocol, and the incident was only investigated after the resident was found with injuries. The failure to promptly report the suspected abuse constituted a violation of the facility's abuse prevention policy.