Failure to Immediately Report Alleged Abuse Involving DON and Administrator
Penalty
Summary
Failure to immediately report an allegation of abuse occurred when staff did not promptly notify the state survey agency after an incident involving a cognitively impaired resident with dementia, Parkinson’s disease, mood disorder, violent behaviors, anxiety, and depression. The resident required maximum assistance with ADLs and had frequent verbal and physical behaviors. On the date of the incident, the Maintenance Director, who was also a nurse aide, was assisting the resident with a brief change when the DON entered and told the resident he/she needed to get cleaned up. The resident yelled at the DON to leave, but eventually agreed to allow the DON to help turn him/her. The DON pulled on the resident, the resident complained of pain, and the DON responded that there was nothing wrong with the resident. The resident began yelling and smacking at the DON, who then let go. The Maintenance Director observed that the resident’s shorts were heavily soiled and obtained the resident’s agreement to be changed. The DON then began grabbing and pulling on the resident’s shorts while the resident held onto them with one hand and yelled for the DON to leave him/her alone, simultaneously slapping at the DON with the other hand. The Administrator entered the room, and at the DON’s direction, grabbed the resident by the hand and elbow and held the arm tightly while the resident kicked and screamed. The resident kicked toward the DON’s face, and the DON responded by saying, “kick me again motherfucker and see what happens.” The Maintenance Director told the DON and Administrator to stop and leave the resident alone, refused to hold the resident’s arms when instructed by the Administrator, and then left the room and the facility. The next day, the Maintenance Director noted small bruises on the resident’s arms that had not been present during bathing the previous day. Multiple staff members witnessed or overheard parts of the incident but did not immediately report the allegation of abuse to the state agency as required by facility policy. The SSD heard the resident yelling and, from the hallway, heard the DON say “kick me again motherfucker and see what happens,” and saw the Maintenance Director exit the room stating he/she wanted no part of it. The SSD and BOM both reported uncertainty about how to report abuse when the alleged perpetrators were the DON and Administrator, noting that their abuse training video instructed them to report to the Administrator but did not address what to do if the Administrator was involved. The Maintenance Director, SSD, and BOM delayed external reporting, and the allegation was not immediately reported to the state survey agency within the required time frames outlined in the facility’s Abuse Prohibition Protocol Manual.
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