Failure to Timely Report Allegation of Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the State Survey Agency immediately, and no later than two hours after the allegation was made. A resident with Parkinson’s disease, schizophrenia, muscle wasting, and atrophy, who was severely cognitively impaired (BIMS score of 5) and dependent on staff for transfers and bed mobility, was the subject of the allegation. The resident used a wheelchair/Broda chair for mobility and required extensive to total assistance, including a two-person assist with a Hoyer lift. An undated written note by a CNA stated that the CNA observed an LVN grab the resident and pull him up by his shirt in what the CNA described as an abusive manner while the resident was in a chair. The CNA documented that the resident said he thought his leg was broken and that the CNA cried because she believed what she saw was very wrong. This note was later found on the floor under the social worker designee’s office door. The social worker designee reported finding the note on a Friday morning and handing it to the Administrator. The DON reported that the incident involving the LVN aggressively pulling the resident up in his Broda chair occurred on or about late December and that the note was found on a Friday in early January. The Administrator stated that she and the social worker designee interviewed the resident, who reported that he had been sliding down in his chair and that the LVN had pulled him up by his shirt. The Administrator also stated that some residents reported being scared of the LVN because he was intimidating. Despite this allegation of abuse and the facility’s own abuse policy requiring that all events involving an allegation of abuse be reported immediately or no later than two hours after the alleged violation, the Administrator acknowledged that she did not report the allegation to the State Survey Agency because the resident said the LVN had only pulled him up by his shirt.
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