Failure to Timely Report Alleged Staff-to-Resident Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse involving one resident to the State Agency (SA) as required by regulation and facility policy. The resident had diagnoses including depression, schizophrenia, quadriplegia, and hypertension, and a recent MDS showed a BIMS score of 10, indicating moderately impaired cognition. On the date of the incident, behavior charting documented that the resident became very upset and physically and verbally aggressive with staff. According to the facility’s suspected abuse investigation report, the resident was attempting to run into staff and other residents with an electric wheelchair in a common area, and a CNA intervened by getting in front of the wheelchair. The resident then kicked the CNA, and the CNA placed the resident into a recliner while yelling loudly. The investigation concluded that the CNA’s loud complaining voice was not appropriate in a behavior setting. However, there was no evidence in the clinical record of a head-to-toe or skin assessment after this altercation. Record review and staff interviews revealed no documentation that this allegation of staff-to-resident abuse was reported to the SA within the required timeframe, and the facility was unable to provide any documentation of reporting when requested by surveyors. The DON and the administrator both described abuse as including physical, verbal, emotional, and financial harm and stated that the facility’s process is to separate the parties, assess the resident for injury, and notify the SA within 2 hours for staff-to-resident incidents. Both the DON and the administrator acknowledged that the incident between the CNA and the resident was not reported to the SA, explaining that they did not consider the CNA’s actions to be intentional abuse. Review of the facility’s policy on identification and investigation of abuse, neglect, misappropriation, and injuries of unknown origin showed that any alleged abuse, including physical or verbal, must be reported to the SA immediately, but not later than 2 hours after the allegation is made, and all other reportable allegations must be reported within 24 hours, which did not occur in this case.
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