Failure to Timely Report Suspected Abuse to Proper Authorities
Penalty
Summary
The facility failed to report an allegation of suspected abuse involving a resident within the time frame specified by facility policy. The incident involved a female resident with multiple medical conditions, including spinal stenosis, chronic kidney disease, and chronic lymphocytic leukemia in remission, who was dependent on staff for toileting and personal hygiene. During a shift, a Certified Nursing Assistant (CNA) observed that the resident did not want her family member (FM) to perform perineal care, but the FM insisted and proceeded to do so aggressively, causing the resident pain and distress. The resident verbally requested the FM to stop, but the FM refused, and the CNA noted redness and irritation in the perineal area, suspecting abuse. The CNA reported the incident to the Registered Nurse (RN), who attempted to report the suspected abuse to Adult Protective Services (APS) and the Ombudsman but was unable to reach them immediately. The RN subsequently reported the incident verbally and in writing to APS the following day and informed the Director of Nursing (DON). However, the RN was unfamiliar with the facility's reporting process and did not know the identity of the abuse coordinator, leading to further delays in proper notification. The Director of Social Services (DSS) and the Administrator were not immediately informed, and the police were not contacted as required by facility policy. A review of the facility's Abuse Prevention and Prohibition Program policy indicated that all staff are mandatory reporters and must report suspected abuse immediately, but no later than two hours after forming a suspicion, to the state survey agency, APS, law enforcement, and the Ombudsman. The policy also specifies that the Administrator or designee is responsible for reporting and that failure to report within the required time frames may result in disciplinary action. In this case, the facility did not adhere to its own policy, resulting in a delay in reporting the suspected abuse to the appropriate authorities.