Failure to Timely Report Resident Abuse Incident
Penalty
Summary
Facility staff failed to report an incident of abuse involving a resident with anxiety, conduct disorder, moderate cognitive impairment, and delusions within the required timeframe. The incident involved multiple certified nurse aides (CNAs) attempting to get the resident up for supper, during which the resident was distressed, yelling, refusing to cooperate, and ultimately ended up naked on the bathroom floor. A gait belt was applied directly to the resident's bare skin, and staff lifted her with it at least once. Several CNAs were reported to have yelled at the resident, pointed in her face, and insisted she apologize. Another CNA later found the resident crying on the floor with scratches on her left arm, which no staff could explain. The resident was then calmed, cleaned, dressed, and brought to supper. The charge nurse was only informed that the resident had a behavior and that a gait belt was used, but was not told about the yelling, the resident being on the floor naked, the number of staff involved, or any injuries. The full details of the incident were not reported to the charge nurse at the time. The facility reported the incident to the State Survey Agency (SSA) six days after the event, which was not within the required two-hour timeframe. An administrative nurse confirmed that the incident was not reported in a timely manner and acknowledged that it was unacceptable for staff to holler at or threaten residents.