Failure to Timely Report Allegation of Abuse to Required Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse within the required 2‑hour timeframe to the State Survey Agency, state ombudsman, and local law enforcement. A cognitively intact resident with chronic kidney disease, anxiety disorder, and COPD, who required substantial to maximal assistance with several ADLs, alleged that a CNA on the 3 PM to 11 PM shift was rough, pushy, and verbally abusive during incontinence care. The resident reported that the CNA yanked a drawsheet from under her, threw it on the floor near the door, pulled out her brief, grabbed her arm, and held it straight up while changing her, preventing her from adjusting the brief tabs as she preferred. The resident stated the CNA was mean, rough, and scary, and that the interaction made her cry. On the evening of the incident, an RN supervisor heard loud voices from the resident’s room, entered, and observed both the resident and the CNA were upset. The resident told the RN supervisor that the CNA had thrown the drawsheet on the floor and was not listening to her request to have two drawsheets. The resident refused further care from the CNA, and her voice was described as shaky. The RN supervisor acknowledged that she recognized this as a possible allegation of abuse but became overwhelmed and busy with her shift and did not report the incident to the Administrator, DON, or another licensed nurse as required. Another CNA later reported that the resident had told her the CNA who took over her care after 7 PM that Sunday was rude to her, but this CNA also did not report the allegation to supervisory staff. The resident reported the incident to the Social Services Director the following day, describing the CNA’s actions with the drawsheet and her perception that the CNA was rough and rude. The Social Services Director did not immediately conduct a thorough investigation or report the allegation to the appropriate agencies at that time. The facility’s policies on Abuse Investigation and Reporting and Abuse Prevention Program required that alleged violations of abuse, neglect, exploitation, or mistreatment be reported immediately, and not later than two hours if the alleged violation involved abuse or resulted in serious bodily injury. The DON confirmed that CNAs are mandated reporters and that staff should have reported the allegation within two hours, including when the resident told a CNA that staff was mean, which the DON identified as possible verbal abuse. Despite these requirements, the allegation was not reported within the mandated timeframe, resulting in the cited deficiency.
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