Failure to Timely Report Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure that an allegation of physical abuse involving a resident was reported in a timely manner to both the Administrator and the State, as required by facility policy. The policy specifies that allegations of abuse or serious bodily injury must be reported to the CEO and the state agency within two hours, and within 24 hours if the event did not involve abuse or serious bodily injury. In this case, a resident with Parkinson's disease and impaired upper extremity range of motion reported to the Unit Manager that a CNA caused pain by pulling a shirt that caught on the resident's umbilical hernia. The resident stated that the CNA continued to pull on the shirt despite being told to stop, causing further discomfort. The incident was initially reported by the resident to the Unit Manager, who documented the event as a late entry in the medical record. The resident also submitted a grievance form describing the incident and alleged that attempts to report the event to other CNAs were unsuccessful. The Administrator became aware of the incident only after the grievance form was placed under his door and did not see it until several days after the initial report. The Administrator stated that the initial report did not meet the threshold for abuse and therefore was not reported immediately. The facility did not report the allegation to the State until four days after the resident's initial report, exceeding the required reporting timeframe. The Administrator confirmed that staff are expected to report abuse allegations to him immediately, but this did not occur in this instance. The delay in reporting the incident constituted a failure to follow the facility's abuse reporting policy and regulatory requirements.