Failure to Immediately Report Witnessed Abuse Incident
Penalty
Summary
A deficiency occurred when staff failed to immediately report a witnessed incident of potential verbal and physical abuse involving a resident with severe cognitive impairment and total dependence on staff for care. The facility's Abuse Prevention Program policy required all employees to immediately report any violations or alleged violations, but this protocol was not followed. An activity aide observed another aide flicking the loose skin under a resident's chin while mimicking a sound and laughing, as well as calling the resident derogatory names after an incident with a tablet. The aide who witnessed the incident did not report it to the Activity Director until the following day and did not provide full details until later that afternoon. Interviews confirmed that the aide recognized the interaction as inappropriate but did not think to report it immediately, despite facility policy. The delay in reporting was acknowledged by both the Activity Director and the Director of Nursing, who stated that the incident should have been reported right away. The resident involved had a diagnosis of unspecified dementia with anxiety, restlessness, and agitation, and was unable to be interviewed due to severe cognitive impairment. The failure to promptly report the observed abuse placed this resident and potentially others at risk, as required procedures for immediate reporting were not followed.