Failure to Timely Report Resident’s Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of staff-to-resident abuse to the State Survey Agency (DHSS) within the required two-hour timeframe, as required by facility policy and state law. The facility’s Abuse and Neglect Policy states that suspected abuse must be reported immediately to administration and to the state licensing agency within two hours for allegations of abuse or those resulting in serious bodily injury. On the date in question, a resident with vascular dementia, diabetes mellitus, and hypertension, who had moderate cognitive impairment and frequently rejected care, alleged that a certified medication tech (CMT) hurt his/her hand during medication administration, including a blood sugar check and insulin injection. According to staff statements, the CMT entered the resident’s room to administer medications, check blood sugar, and give insulin. The resident became irate, claimed injury to his/her hand, and began swatting and throwing water at the CMT. The CMT reported to an LPN that the resident accused him/her of hurting the resident’s hand, and the LPN and ADON were informed of the accusation. The LPN documented in a progress note that the resident became upset, threw water, and yelled at staff, but did not document the resident’s allegation that staff caused injury to the hand. Multiple staff, including a CNA, reported hearing the resident hollering and the resident stating that staff hurt his/her hand or gave him/her a bruise, and one CNA reported that the resident pointed at the CMT and said, “He gave me that bruise.” Staff interviewed acknowledged that hitting or hurting a resident’s hand would be considered abuse and that such allegations should be reported to the state within two hours. The ADON and Administrator were made aware of the situation. The ADON stated that his/her understanding was that the resident said the CMT hurt his/her finger during a finger stick, which the resident reportedly says often, and that he/she noted old bruising on the resident’s hands but no new bruising. The Administrator reported being notified that someone hurt the resident’s hand and, upon questioning the resident, was told that a man who got the resident out of bed grabbed the resident’s hand too tightly, while the resident denied that the employee giving medications hurt him/her. The Administrator also noted bruising on the resident’s hands and stomach, which he/she believed related to lab draws and insulin injections. Despite these allegations and assessments, DHSS records showed the facility did not report the allegation of possible abuse on that date, and the Administrator later acknowledged that he/she should have reported and followed policy regarding the initial abuse report. Further observation and interview with the resident showed multiple bruises on both hands, including circular reddish-purple and purple bruises of various sizes, and the resident reported obtaining the bruises when staff helped him/her out of bed. Staff interviews consistently reflected knowledge that abuse allegations must be reported promptly to administration and to the state within two hours. However, the allegation that staff hurt the resident’s hand and caused bruising was not reported to DHSS within the required timeframe, constituting the failure to ensure all allegations of possible abuse were timely reported to the State Survey Agency as required by facility policy and regulation.
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