Failure to Timely Report Alleged Abuse Involving Oxygen Mask Application
Penalty
Summary
The facility failed to ensure that an alleged abuse incident was reported immediately, but not later than two hours after the allegation was made, as required by policy and HHSC reporting guidelines. The incident involved a female resident with dementia, dehiscence of a surgical wound, bronchopneumonia, and a need for continuous oxygen therapy. Her care plan documented impaired gas exchange and the need for frequent redirection to keep her oxygen mask on. On the date of the incident, a laundry aide reported entering the resident’s room and observing an LVN yelling at the resident to keep her oxygen mask on or she would go to the hospital, and forcefully pushing the oxygen mask onto the resident’s face and pulling the straps into place. The laundry aide immediately reported the allegation to the Maintenance Director, consistent with her abuse/neglect training, and wrote a statement describing the LVN’s alleged verbal and physical actions. The Maintenance Director then notified the ADON and provided the written statement. The ADON went to the resident’s room and spoke with a sitter from the state hospital who was present during the incident. The sitter reported that the LVN had been blunt with the resident about keeping the mask on and the risks of taking it off, but the ADON stated that the sitter did not report that the LVN forcefully placed the oxygen mask on the resident’s face. Based on her interviews, the ADON determined the incident was not reportable and did not notify the Administrator or HHSC within the required timeframe. Subsequent interviews revealed discrepancies between what was reported to the ADON and what witnesses stated to the surveyor. The sitter later told the surveyor that the LVN yelled at the resident to put the mask back on, forcefully put the mask on while saying, "If you don't put this mask on you're going to die," and that the resident appeared frightened. The laundry aide confirmed she was never interviewed by the ADON beyond providing her written statement. The Administrator reported she was not notified of the incident until two days after it occurred and was unaware of the laundry aide’s written statement until the survey. The DON stated that, per policy, abuse allegations should be reported immediately to the Administrator or, in her absence, to a supervisor, and acknowledged that this allegation was not reported to the Administrator as required.
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