Failure to Immediately Report and Protect Resident Following Staff-to-Resident Abuse
Penalty
Summary
The facility failed to follow its abuse policies and procedures regarding the immediate reporting of an allegation of staff-to-resident abuse and the protection of the resident involved. According to the facility's abuse policy, all staff are required to report any allegations, suspicions, or incidents of abuse or neglect to the Administrator or Abuse Coordinator immediately, but no later than two hours after the event. In this incident, two nurse aides witnessed a nurse physically restrain a resident, curse and spit at the resident, and place a pillow over the resident's face during incontinence care. Both aides acknowledged awareness of the abuse policy and recognized the actions as abuse, but neither reported the incident until the following day when they returned for their next shift, well beyond the required reporting timeframe. The resident involved had severe vascular dementia with psychotic disturbance, cognitive communication deficit, anxiety, delusional disorder, depression, and chronic pain with peripheral neuropathy. During the incident, the resident became agitated, screamed, and attempted to resist care, leading to the nurse's inappropriate actions. The nurse aides reported feeling shocked and needing time to process the event, which contributed to their delay in reporting. As a result of the delayed reporting, the accused nurse was able to complete the remainder of her shift and continued to be assigned to the resident, contrary to the facility's policy that requires immediate removal of staff accused or suspected of abuse. The deficiency was further evidenced by the fact that the incident was not reported to the administration until the next day, delaying the initiation of an investigation and the removal of the accused nurse from duty. The resident was later assessed and found to have discoloration and a small scratch on her right wrist. The failure to immediately report the abuse and protect the resident was confirmed through staff interviews and record review, demonstrating noncompliance with the facility's established abuse prevention policies.