Delayed Reporting of Suspected Abuse
Penalty
Summary
Staff failed to immediately report an allegation of physical abuse involving a resident with severe cognitive impairment, dementia, depression, and hypertension. The incident occurred when a Certified Nurse Aide (CNA) witnessed another CNA slap the resident on the head while the resident was sleeping in a wheelchair. The witnessing CNA did not report the incident immediately due to fear of retaliation, instead waiting approximately eleven days before informing an LPN. The LPN then reported the allegation to the Director of Nursing, and the incident was subsequently reported to the Administrator and the State Department of Health. Facility policy required all staff to immediately report any observed or suspected abuse to the Administrator, Director of Nursing, or designee, and for the Administrator or designee to notify state agencies within two hours. However, the delay in reporting by the CNA resulted in the Administrator and state authorities being notified well outside the required timeframe. Interviews with staff confirmed knowledge of the reporting requirements and acknowledged that the delay was unacceptable.