Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident and a certified nursing assistant (CNA) was reported to the State Agency within the required timeframe. The incident occurred when a resident, who was cognitively intact and had diagnoses including Type 2 Diabetes and depression, was involved in a verbal altercation with a CNA. The altercation included yelling and accusations, with the CNA being antagonistic and the resident making personal accusations against the CNA. The situation was witnessed by an LPN, who intervened and separated the individuals, ensuring the resident felt safe. The CNA was instructed not to interact with the resident further during the shift, but was not immediately suspended or removed from the care area as required by facility policy. The LPN who witnessed the incident reported it to the nurse on call later that night, but the nurse on call did not provide direction to remove the CNA from the facility or report the incident to the Director of Nursing (DON) or Nursing Home Administrator (NHA) until several days later. The incident was not reported to the State Agency until the following day, exceeding the facility's policy and federal requirements to report allegations of abuse immediately, but no later than two hours after the allegation is made. Interviews with staff confirmed that the incident was recognized as an allegation of abuse and that the reporting requirements were not met. Facility records and staff interviews indicated that the delay in reporting was due to a lack of immediate action by both the nurse on call and other supervisory staff. The facility's own policies require immediate notification of the administrator and State Agency in cases of alleged abuse, as well as immediate suspension of implicated staff. These procedures were not followed, resulting in a failure to timely report the suspected abuse as required.