Delayed Reporting of Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure that an allegation of physical abuse was reported immediately to the Administrator and the State Survey Agency, as required by policy and regulation. A certified nursing assistant (CNA) witnessed another CNA allegedly grab a resident's hair and slam the resident's face into the mattress after the resident spat in the CNA's face during care. The witnessing CNA did not report the incident immediately due to fear of retaliation, instead leaving a note for the Director of Nursing and informing a nurse supervisor the following day. This resulted in a delay of approximately one day before the incident was brought to the attention of facility leadership. The resident involved had diagnoses including Alzheimer's disease, anxiety, and depression, and was assessed as severely cognitively impaired with a history of confrontational behavior. At the time of the survey, the resident was observed to be calm, pleasant, and showed no signs of physical abuse. Staff were seen treating the resident with respect and dignity during the observation period. Interviews with facility staff confirmed that the abuse allegation was not reported within the required two-hour timeframe. The Director of Nursing and Administrator both acknowledged that the delay in reporting was unacceptable and not in compliance with facility policy or state regulations. The incident was ultimately reported to the State Agency two days after it occurred, rather than within the mandated period.