Failure to Timely Report Alleged Abuse Involving Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of abuse involving a cognitively impaired male resident with multiple medical conditions, including metabolic encephalopathy, bipolar disorder with psychotic features, muscle weakness, and a history of falls. The resident required extensive assistance with transfers, bed mobility, toileting, dressing, and bathing, and had a BIMS score of 6, indicating moderate cognitive impairment. On the date of the incident, nursing documentation noted the resident was heard screaming loudly and continuously; a CNA entered the room and reported that the resident appeared irritated and agitated, screamed at her, struck her four times, and attempted to strike her in the face. The CNA stated she grabbed the resident’s arm to prevent injury to herself, and the resident pulled his arm away, resulting in a 5 cm x 2.5 cm skin tear to the left forearm. Subsequent nursing documentation recorded discovery and treatment of the skin tear, including cleansing with normal saline, application of steri-strips, and notification of the NP and the administrator later that day. The resident’s family member reported being notified by the facility that a CNA had grabbed the resident’s arm and caused a laceration during ADL care, and stated she had video showing the CNA grabbing the resident’s arm while assisting him back to bed, although she did not provide the videos. Interviews with staff confirmed the physical interaction: the CNA reported that during ADL care the resident struck her multiple times in the chest, and she reacted by grabbing his hand to block further hits, which caused a small skin tear. An LVN who was present stated she saw the resident attempt to hit the CNA, who then grabbed the resident’s hand, causing the skin tear, and reported the incident to the DON and administrator. The administrator stated she was on vacation and out of the country when she was notified of the incident involving the CNA grabbing the resident’s arm and causing a skin tear. She identified the DON as the assigned abuse coordinator and said the DON should have reported the incident to the state, but acknowledged she did not personally report the incident, investigate the allegation, or suspend the alleged perpetrator, and assumed the DON had called the incident into the state. The CNA and LVN both indicated they reported the incident to the DON and administrator, and the CNA identified the administrator as the facility’s abuse coordinator. Review of the facility’s Abuse Investigation and Reporting policy, revised July 2017, showed that all alleged violations involving abuse, neglect, or injuries of unknown source must be reported immediately, but no later than two hours if abuse or serious injury is suspected, to the administrator and appropriate agencies, including the State Survey Agency. The facility failed to ensure this allegation of abuse was reported within the required two-hour timeframe as required by federal and state regulations and facility policy.
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