Failure to Timely Report Staff-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of staff-to-resident abuse to the State Survey Agency (SSA) in accordance with federal and facility policy requirements. A resident with dementia with behavioral disturbances, restlessness and agitation, bipolar disorder, and a BIMS score of 3/15 indicating severe cognitive impairment, was involved in a combative episode with a CNA during care at approximately 10:00 PM. During this episode, the resident became physically and verbally aggressive, and subsequently sustained a skin tear to the right fourth finger and a bruise under the right eye/cheekbone area. The CNA reported the combative episode and resulting injury to an RN, stating that the resident had grabbed the CNA’s wrist and that the skin tear occurred when the CNA pulled her hand back. The resident told the RN that the CNA had punched her, and the RN notified an LPN of both the incident and the abuse allegation at approximately 10:15 PM. The LPN told the RN that the DON would be notified, but the LPN did not contact the DON that night. The DON did not become aware of the incident and allegation until 7:00 AM the following morning. The facility did not notify the SSA of the staff-to-resident abuse allegation until 5:39 PM that day, exceeding the facility’s policy requirement that all allegations of abuse be reported immediately to the Administrator, DON, and SSA, and that allegations of abuse be reported to the Department of Health immediately, but not later than two hours after the allegation is made. This delay in internal notification and external reporting constituted the deficiency identified by surveyors.
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