F0609

E

Failure to Timely Report Allegations and Incidents of Abuse and Neglect

New Castle, Delaware Survey Completed on 12-13-2025

Penalty

No penalty information released

Summary

The facility failed to ensure timely reporting of multiple allegations and incidents of potential abuse and neglect, contrary to its policy requiring immediate reporting to the Administrator/DON and the State Agency. For one resident with traumatic brain injury and dementia with agitation, a nurse’s note documented that the resident attempted to enter two female residents’ rooms, tried to get into bed with one of them, and that the resident threatened to call 911 if the behavior recurred. The note stated the DON was notified and a room change was recommended, but there was no corresponding entry on the Incident and Accident Report Log, and no evidence in the facility or resident records that this potential resident‑to‑resident abuse was reported to administration or to the State Agency. During interview, the Administrator and DON confirmed such incidents should be logged and reported within two hours, and the DON denied being notified as documented.

The facility also failed to promptly report a resident‑to‑resident incident involving two other residents. One resident, cognitively intact and ambulatory, attempted to propel his wheelchair around another resident who used a front‑wheeled walker and was moderately cognitively impaired. When the second resident refused to move, the first resident grabbed the wheelchair handles and pulled back, causing the second resident to fall and sustain a skin tear on the right elbow, for which nursing provided assessment and Tylenol. Although the incident occurred on one date, the Facility Reported Incident form showed it was not reported to the State Survey Agency until two days later. In interview, the Administrator stated that the RN involved failed to report this resident‑to‑resident incident to her immediately, despite the expectation that staff notify her right away of any alleged resident‑to‑resident abuse.

In another case, the facility delayed reporting an allegation of staff roughness made by a cognitively intact resident with multiple medical conditions, including sepsis history, muscle weakness, COPD, chronic pain, depression, and diabetes, who used a wheelchair and required assistance with ADLs. During a shift, a CNA checked the resident’s brief after the resident stated she was not wet and would notify staff if needed; the CNA continued the check, and the resident struck the CNA’s arm, stating the CNA was being too rough and causing pain. The CNA told the resident not to put hands on her and left the room, and the nurse present documented the resident’s statements that the CNA was rough and had an attitude, and that she would call her children to remove her from the facility. The Facility Reported Incident indicated the Administrator was not notified until the following day, constituting a delay in notification under the facility’s abuse policy, which requires immediate reporting of all allegations of abuse, neglect, injuries of unknown origin, and misappropriation to the Administrator/DON and State Agency, and reporting of abuse or serious bodily injury to the Department of Health no later than two hours after the allegation is made.