Failure to Immediately Report and Protect Resident Following Allegation of Rough Handling
Penalty
Summary
The facility failed to follow and implement its abuse policy and procedures in the case of a resident with multiple diagnoses, including unspecified dementia, chronic obstructive pulmonary disease, and chronic pain. The resident reported that a nursing assistant (NA) was rough and manhandled him during a shower, and despite the resident's repeated requests for the NA to stop, the care continued. The resident expressed fear and distress, stating that staff did not listen when he tried to report the incident after returning to his room. Two nursing assistants were aware of the resident's allegations: one directly involved in the incident and another who overheard the resident's complaints. Neither assistant reported the incident to administration or the charge nurse as required by facility policy, allowing the NA in question to complete the shift and return to work the following day. The charge nurse on duty did not recall being informed of the incident, and the resident's representative did not immediately report the allegation to staff, only doing so during a subsequent visit after the resident repeated his account and appeared upset. The facility's policy required immediate reporting of any abuse allegations to the Administrator and safeguarding of the resident. However, the delay in reporting resulted in the accused NA continuing to work and potentially exposed other residents to risk. The initial assessment and documentation of the resident's condition were also delayed, with the skin and pain assessment not documented until days after the incident. Staff interviews revealed a lack of awareness or recall regarding the reporting of the incident, and the facility's investigation confirmed that the abuse allegation was not reported promptly as required by policy.