Delayed Reporting of Alleged Staff-to-Resident Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to effectively implement its abuse, neglect, and exploitation policy by not ensuring that staff immediately reported an alleged incident of staff-to-resident abuse to the NHA or designee. The facility’s policy required employees, consultants, physicians, family members, and visitors to promptly report suspected incidents of neglect or abuse to facility management, specifically to the Administrator, DON, or designee, and to other officials and the state survey agency as required. Despite this policy, an incident involving a CNA throwing a tablet cover that struck a resident’s coffee cup and spilled coffee into the resident’s lap was not promptly reported through the appropriate chain of command, resulting in a delay of approximately 17 hours before the DON was notified of the potential abuse allegation. The resident involved, identified as Resident #101, had diagnoses including dementia, early onset Alzheimer’s disease, anxiety, and depression, and had a BIMS score of 13 indicating cognitive intactness. The resident’s care plan documented a history of significant trauma, including past verbal and physical abuse by her father, a mother with mental health issues, and abusive or controlling spouses, as well as a trauma and stressor-related disorder. The resident reported that when people are mean to her, she tends to shut down, and described that on one occasion in the facility, a CNA had a temper tantrum and threw something that knocked her coffee onto her lap. The resident stated she had forgiven the CNA and did not want to dwell on the incident. Multiple staff interviews detailed the sequence of events and the delayed reporting. CNA K stated that while cleaning a tablet cover, she became frustrated when the resident and another CNA teased her, and she tossed the cover toward the other CNA, knocking over the resident’s coffee onto her lap. CNA M confirmed that she observed the incident, felt the CNA’s behavior was inappropriate in front of the resident, but did not immediately report it; instead, she sought advice later in the day from life enrichment staff, who in turn consulted another staff member and suggested placing a written statement in an RN’s mailbox rather than immediately notifying a nurse. The concern was eventually reported to an LPN around the early evening, who passed it to the next nurse on duty. That RN delayed further action until after midnight, at which point the house supervisor was contacted and video footage was reviewed, showing the CNA looking at the resident and throwing the tablet cover, which hit the resident’s cup and spilled coffee into her lap. The DON and NHA both reported that they were not promptly informed of the full nature of the incident, and the record notes that approximately 17 hours elapsed between the incident and the DON being notified of the potential abuse allegation.
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