Failure to Timely and Accurately Report Resident Abuse Allegation
Penalty
Summary
The facility failed to follow its abuse, neglect, and exploitation policy requiring immediate reporting of abuse allegations to the Administrator, State Agency, Adult Protective Services (APS), and law enforcement when applicable, within two hours of the allegation. A cognitively intact resident reported to the Admissions Director that a nurse aide had hit her in the face multiple times during a shower/bed bath, describing the staff member as a Black woman with pearls in her hair. The Admissions Director documented the concern on a grievance form but did not notify nursing staff, the DON, or the Administrator until the following morning during a meeting, citing that it was late, had been a long day, and that she had not observed any visible injuries on the resident at the time. As a result, the Administrator recorded the facility’s awareness date and time of the allegation as the following day, rather than when the Admissions Director first received the report from the resident. The initial allegation report completed by the Administrator documented that the facility first became aware of the abuse allegation on the later date and did not reflect the actual date and time the allegation was first reported to staff. The initial report was faxed to the State Agency several hours after the Administrator was informed, and the initial documentation did not show that APS or law enforcement were notified at that time. A subsequent skin assessment by a nurse, completed at the request of the Facility Nurse Consultant, documented no signs of facial trauma or other skin issues aside from a pressure spot on the resident’s toe. Interviews with the DON and Administrator confirmed that staff were expected to report any abuse allegation immediately so it could be reported to the State Agency within two hours, and that the Admissions Director did not follow this requirement, resulting in delayed and inaccurate reporting of the abuse allegation.
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