Failure to Timely Report Alleged Resident Mistreatment
Penalty
Summary
Staff failed to report an allegation of mistreatment involving a resident with severe cognitive impairment and a history of traumatic brain injury, dysphagia, and aphasia. The incident occurred when a nurse aide (NA) overheard another NA threaten not to feed the resident if certain behaviors continued. The NA who witnessed the event informed an LPN, who did not escalate the report as required, instead instructing the NA to report it to the Director of Nursing Services (DNS) or Administrator. The DNS was not notified until three days after the incident, delaying the initiation of the facility's investigation. Facility documentation and staff interviews confirmed that the resident was unable to communicate about the incident due to cognitive impairment. The facility's policy required immediate reporting of any suspicion of abuse or neglect, but both the NA and LPN failed to follow this protocol. The delay in reporting resulted in a late notification to the state agency, which should have occurred within two hours of the allegation according to facility policy.