Failure to Timely Report Alleged Abuse and Injuries of Unknown Source
Penalty
Summary
The facility failed to ensure that all allegations of abuse, including injuries of unknown source, were reported immediately, as required. A resident who is deaf and mute, but cognitively intact, was admitted with multiple medical conditions including recent back surgery and was receiving anticoagulation therapy. Upon admission, the resident reported experiencing significant pain and alleged that two nurses hit her on her abdomen and back when she was unable to open her legs for care. The resident attempted to communicate her distress and allegations to staff through handwritten notes and also contacted 911, resulting in police visiting the facility. Despite these efforts, the initial allegations were not reported to the appropriate administrative staff or authorities in a timely manner. Multiple staff members, including a registered nurse and a physical therapist assistant, became aware of the resident's allegations but did not immediately escalate the report to facility administration or external authorities. The registered nurse admitted to receiving a handwritten note from the resident about the alleged abuse but assumed the next shift would handle the report and did not notify the administrator or supervisor. The physical therapist assistant eventually reported the incident to her supervisor and the administrator, but this occurred several days after the initial allegation. Facility records did not show a timely report of the abuse allegation, and the administrator only became aware of the situation after being informed by the therapist assistant. When the administrator was finally informed, she initially reported the incident to the state agency and police but later withdrew the report, categorizing it as a grievance due to perceived communication issues. It was not until nearly three weeks after the initial occurrence that the administrator interviewed the resident with an interpreter and reported the allegation to the agency. Documentation and interviews confirmed that the facility did not follow required protocols for immediate reporting of abuse allegations, resulting in a significant delay in addressing the resident's concerns.