Failure to Timely Report Suspected Physical Abuse and Injury
Penalty
Summary
The facility failed to implement its policies and procedures for the timely reporting of a reasonable suspicion of physical abuse involving a resident with severe cognitive impairment and multiple medical conditions, including dementia and a recent right shoulder dislocation. On the night in question, a CNA observed another CNA forcefully twisting the resident's right arm behind their back during care, causing the resident to squirm and attempt to free themselves. The observing CNA did not immediately report the incident to the unit charge nurse due to fear of retaliation and instead reported it to the Nursing Home Administrator (NHA) approximately two hours later. The resident was later found to have a dislocated shoulder and was transferred to the hospital for treatment. The facility's policy required immediate reporting of abuse allegations to the Administrator and the State Agency, especially when serious bodily injury is involved. However, the incident was not reported to the appropriate authorities within the required timeframe, and the NHA did not report the involved CNA's license to the state agency as required. The delay in reporting and failure to follow established procedures resulted in the abuse going unreported in a timely manner, placing the resident at further risk.