Failure to Implement Abuse Reporting Policy Resulting in Delayed Investigation
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy when an allegation of staff-to-resident abuse was made, resulting in delayed internal reporting, investigation, and protection of the resident. The facility’s policy dated 9/1/24 required that all alleged violations be reported immediately, but no later than two hours after the allegation, to the Administrator, State Agency, APS, and other required agencies when applicable, and that an immediate investigation and protective measures be initiated. Resident #1, who had dementia without behavioral disturbances, was allegedly subjected to physical abuse when Nurse Aide (NA) #1 observed NA #2 push Resident #1’s head to the side with an open hand placed above her ear and temple area sometime in September 2025. NA #1 believed that putting hands on a resident in this manner would be considered abuse but did not report the incident at the time and continued to observe NA #2 working on the floor, including providing care to Resident #1, after the incident. Months later, during the last week of January 2026, NA #1 informed an agency nurse (Nurse #1) that he had witnessed NA #2 hit Resident #1 on the side of the head in the past, and he demonstrated the motion, which Nurse #1 interpreted as NA #2 popping the resident’s head with an open hand. Nurse #1 believed the incident should have been reported but did not notify facility leadership, including the DON or Administrator, as required by policy; instead, after her shift she contacted APS directly. The Administrator later documented that APS came to the facility on 1/30/26 to investigate an allegation that NA #2 slapped Resident #1. Interviews with the DON and Administrator confirmed that staff were expected to report suspected or observed abuse immediately to a supervisor and that the supervisor must immediately notify the Administrator so the facility could promptly investigate and protect the resident. Both NA #1 and Nurse #1 failed to follow the facility’s abuse reporting policy, leading to delayed notification of the Administrator and delayed facility investigation and protective actions for Resident #1.
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