Failure to Timely Report Alleged Verbal and Physical Abuse to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within the required 2-hour timeframe. Resident #1 had diagnoses of non-Alzheimer’s dementia, anxiety disorder, and muscle weakness, with a BIMS score of 8 indicating moderate cognitive impairment. According to staff statements, Resident #1 was being assisted in a wheelchair to his room when he was yelling out, which staff described as normal for him. Staff B, a CNA, reported that Staff D, a CNA, came from behind the nurse’s station, grabbed the resident’s lips together with her thumb and index finger for approximately five seconds, and told him to “shut the fuck up.” Staff A, an LPN, did not witness the pinch but heard what was said to the resident and saw Staff D’s hand moving away from the resident’s face. Staff A documented the concern and left a note for the DON, then later messaged the DON the following evening asking if the note had been received. The DON was not working that day and did not become aware of the allegation until approximately 5:00 p.m. the following day, at which time she contacted Staff A and learned of the alleged incident. The DON confirmed that Staff D completed her full shift on the day of the alleged incident and worked again the following day before the DON became aware of the situation. Facility intake information showed the self-report to DIAL was submitted the evening after the DON learned of the allegation, which was more than 2 hours after the initial allegation was made to Staff A. Facility policy required that all allegations of abuse be reported immediately to the charge nurse, that the charge nurse immediately notify the Administrator or designee, and that all allegations be reported to the Iowa Department of Inspections and Appeals no later than 2 hours after the allegation is made.
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