Failure to Immediately Report Suspected Abuse by DON
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported suspected abuse to the State Survey Agency and the Administrator as required by federal regulation and the facility’s Abuse Prohibition policy. The policy, dated 10/24/2022, designated all employees as mandated reporters who must immediately report any reasonable suspicion of a crime against a resident, required anyone witnessing suspected abuse to report it immediately to a supervisor, and required the notified supervisor to immediately inform the Administrator, who in turn must report to the SSA and local authorities within two hours of the allegation. Despite this policy, multiple staff members who either witnessed or were informed of an incident involving a resident were aware of their reporting obligations but did not report the suspected abuse in a timely manner. The resident involved had a history of stroke, hemiparesis, dementia, bipolar disorder, and anxiety disorder, with a comprehensive assessment showing moderately impaired cognition, dependence on two staff for bed mobility, bowel incontinence, and a Stage 4 sacral pressure ulcer requiring dressing changes. On a day in late December, during a dressing change performed by the DON after the resident had a bowel movement that soiled the wound dressing, three NAs were present in the room. One NA reported that while they were holding the resident during the treatment, the DON slapped the resident on the bare buttock after completing the dressing change. The resident questioned the action, asking what it was for, and the DON responded that it was “just to let you know I was done.” The NA who witnessed this stated they felt very uncomfortable and later told the other two NAs they intended to report the incident to the hotline, but did not actually report it until about 30 days later, after leaving employment at the facility. Two other NAs present during the incident confirmed witnessing the DON slap the resident’s bare buttock but did not report the event. One NA stated they did not think it was abuse and believed it was playful behavior, and therefore did not report it to the Administrator or the hotline. The other NA, who understood the concept of being a mandatory reporter and knew about the state hotline, stated they did not call because the NA in training said they were going to report it. Additionally, a RN/Resource Clinician reported that the DON later told them they had “tapped” the resident on the buttock and that staff in the room had reacted with concern; the RN spoke with the resident hours later and noted the resident did not seem aware of the action, but the RN acknowledged they should have reported the incident that day and did not. The Administrator confirmed they had received no reports of inappropriate behavior by the DON and were unaware of this incident until informed by the surveyor, demonstrating that the required immediate reporting to the Administrator and SSA did not occur.
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