Failure to Timely Report Allegation of Staff-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an allegation of possible physical abuse was reported immediately to management and within two hours to the State Survey Agency, as required by facility policy. The facility’s abuse policy states that every staff member must immediately report any observed or suspected abuse and that the DON will ensure all alleged violations involving abuse are reported not later than two hours after the allegation is made. In this case, staff became aware of an allegation of possible staff-to-resident physical abuse on the evening of 01/27/26, but administration and the Department of Health and Senior Services (DHSS) were not notified until the following day, approximately 16 hours after the initial report to the charge nurse. The resident involved had severe cognitive impairment, hemiplegia of the left side, diabetes mellitus, and high blood pressure, and was dependent on staff for all ADLs, using a wheelchair. The resident’s care plan noted that the resident could be resistive to care at times and that staff should provide clear explanations of care activities. On the evening of 01/27/26, a CNA responded to the resident’s call light for incontinence care. Shortly afterward, another CNA observed this CNA running down the hall with blood on the CNA’s face. The resident later stated that the CNA had punched the resident in the stomach and leg, and that the resident did not want that CNA in the room anymore. The CNA who heard this allegation reported it to the charge nurse (LPN A), who then questioned the resident. LPN A documented in a progress note that the CNA reported having a bloody nose and lip after the resident allegedly hit the CNA, and that the DON and physician were notified. However, the progress note did not document the resident’s allegation that the CNA had punched the resident. During interview, LPN A stated that the resident reported the CNA had punched the resident in the right leg, and that LPN A texted the DON and physician about the incident but received no response and was unsure what to do next. Administration did not become aware of the allegation until late morning on 01/28/26, and the self-report to DHSS was submitted shortly thereafter, 16 hours after the incident was initially reported to the charge nurse, contrary to the policy requirement for reporting within two hours of an abuse allegation.
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