Failure to Timely Report Allegation of Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse to the Iowa Department of Inspections, Appeals, and Licensing (DIAL) within the required 2-hour timeframe. The involved resident had severe cognitive impairment, with a BIMS score of 5, and diagnoses including heart failure, hypertension, and traumatic brain injury. A CNA reported that while assisting a radiology technician in positioning the resident for an x-ray, she observed the technician place a gloved hand over the resident’s mouth due to coughing and tell or ask the resident to stop coughing. The CNA then reported this observation to the nurse on duty. The RN confirmed that the CNA reported the technician put a hand on the resident’s mouth and told or asked the resident to quit coughing, and that the CNA’s description made it sound shocking. The RN stated she did not consider this an allegation of abuse and did not report it to the Administrator or DON. A late-entry Health Status Note documented that the following morning the day-shift front nurse informed the ADON, upon arrival to the building, that the radiology technician had put a hand over the resident’s mouth and asked the resident not to cough the previous night, and that the CNA had reported this to the evening nurse. When the ADON spoke with the resident and asked if anything had happened since the previous day, the resident replied that they did not think so. The ADON then reported this information to the DON and Administrator. The facility’s abuse prevention, reporting, and investigation policy required that all allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation be reported to DIAL and other required agencies, with abuse or abuse resulting in bodily injury to be reported immediately and not later than 2 hours after the allegation is made. Despite this policy, the facility did not submit the self-report related to this incident until later that day, beyond the 2-hour reporting requirement.
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