Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to timely report an allegation of staff-to-resident abuse involving a resident with multiple complex medical diagnoses, including major depressive disorder, cirrhosis of the liver, liver transplant, severe alcohol dependence, and chronic kidney disease. On the morning in question, a CNA was accused by the resident of causing water to flood the room and subsequently of pushing him after a verbal exchange. The CNA denied leaving the water running or pushing the resident, stating she was several feet away when the resident moved himself into his wheelchair. The incident was documented in the nurse's note, and the CNA reported the situation to the DNS, who then reported it to the Executive Director (ED). Statements were written and left in the ED's office, and the resident was monitored and found to be in good spirits later that day. Despite the facility's policy requiring immediate reporting of abuse allegations to the ED and the Indiana Department of Health (IDOH), the allegation was not reported to the IDOH until the following day, after the ED became aware of the situation. Interviews confirmed that the DNS reported the incident to the ED on the day it occurred, but the ED did not report to the IDOH until the next day. The facility's policy clearly states that all abuse allegations must be reported to the ED immediately and to the state agency within two hours if abuse or serious bodily injury is involved. This delay in reporting constituted a failure to follow established protocols for timely notification of suspected abuse.