Failure to Timely Report Witnessed Allegation of Possible Abuse
Penalty
Summary
The facility failed to ensure that an allegation of possible abuse was reported immediately to management and within two hours to the State Survey Agency as required by policy. A cognitively impaired resident with Alzheimer's disease, known verbal and physical behaviors, and a care plan addressing potential physical aggression and resistance to care was involved. During toileting and incontinence care, the resident became combative and bent a CMT's finger back. In response, the CMT bent the resident's fingers back and stated, "you like that" or "how does that feel," which a CNA witnessed and believed could be abuse. The CNA who witnessed the incident did not report it to a nurse or management at the time it occurred. Instead, the CNA discussed the event with another CNA later during a lunch break and was advised to report it to the LPN. The CNA went home after the shift and did not report the allegation until the following day during the next shift, resulting in the facility notifying the DON, Administrator, and State Survey Agency the day after the alleged abuse occurred. Interviews with multiple staff, including CNAs, CMTs, nurses, the DON, and the Administrator, confirmed that staff were aware of the requirement to report suspected abuse immediately, and the DON and Administrator stated they expected all staff to report allegations of abuse without delay.
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