Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or exploitation were reported immediately, but not later than two hours after the allegation was made, as required by state and federal regulations. Specifically, a nurse aide in training (NAIT) witnessed what he believed to be an incident of physical and mental abuse involving a resident and a certified nurse aide (CNA) during a transfer for bathing. The NAIT observed the resident, who had a history of combative behavior and severe cognitive impairment, strike a CNA, after which the CNA allegedly retaliated by hitting the resident on the arm. The NAIT did not report the incident immediately, instead waiting three days before informing the charge nurse. The resident involved was a female with a diagnosis of cerebral infarction and a severely impaired cognitive status, as indicated by a BIMS score of 3. Her care plan noted a tendency for combative behaviors, including hitting and biting during care. Interviews with the CNAs involved revealed that both denied hitting the resident, stating that the resident had struck one of them during the transfer, but no staff member struck the resident in return. The resident herself denied ever being physically abused by staff, though she acknowledged sometimes becoming aggressive during bathing due to discomfort. Upon learning of the allegation three days after the incident, the administrator reported the event to the appropriate authorities within the required two-hour window. The facility's policy mandates immediate reporting of all alleged or suspected abuse, but the delay in initial reporting by the NAIT constituted a failure to comply with these requirements. The delay in reporting could have placed residents at risk for potential abuse, as the alleged incident was not promptly investigated or addressed.