Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to timely report an allegation of employee-to-resident abuse involving Resident 2 to the State Survey Agency, Ombudsman, and local law enforcement within two hours as required by its abuse policy. Resident 2 had been admitted with dementia, Alzheimer's disease, and generalized weakness, and a subsequent H&P documented that the resident did not have capacity to understand and make decisions. An MDS later indicated Resident 2 could sometimes understand others and make self-understood and required staff supervision for toileting and showering. On the date of the incident, progress notes documented that Resident 2 became verbally and physically restless and angry before a shower, then calmed and agreed, but became physically aggressive, yelled, and spit at CNA 1 during the shower. During interviews, CNA 2 reported that while CNA 1 was showering Resident 2 and CNA 2 and a student were showering another resident in the same shower room, the resident became agitated. After the shower, Student 1 told CNA 2 that CNA 1 had slapped Resident 2 in the face. CNA 2 stated she instructed the student to report it and the student said she already had, and CNA 2 did not report the allegation directly to the Administrator, even though she acknowledged she should have. The Director of Staff Development stated CNA 1 reported only that Resident 2 became combative and spit at her, and that CNA 1 tried to block the spit with her hands. The Administrator, referencing the facility’s abuse and mistreatment policy, confirmed that all alleged and substantiated violations must be reported to the state agency and other required agencies within two hours, and stated that CNA 2 did not report the allegation on the day of the incident, resulting in the failure to meet the facility’s reporting requirements. The Administrator stated that not reporting allegations of abuse could cause Resident 2 psychological distress and potentially further abuse.
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