Failure to Timely Report Resident’s Allegation of Abuse to Abuse Coordinator
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all alleged violations involving abuse and neglect were reported immediately, but no later than 24 hours, to the administrator/abuse coordinator and proper authorities. A cognitively intact female resident with a history of type 2 diabetes, mild protein-calorie malnutrition, hypertension, prior stroke with upper limb monoplegia, muscle weakness, unsteadiness, and lack of coordination reported that her former roommate had slapped her on the thigh several weeks earlier after a dispute over food items. The resident stated she told multiple CNAs within a few days of the incident, as well as her family member the day after it occurred, but she could not recall the staff members’ names. She later specifically recalled informing one CNA (CNA A) about the incident several days after it happened. Record review showed that during a later counseling session, the licensed professional counselor (LPC) learned of the allegation and relayed it to the social worker (SW), who then reported it to the administrator/abuse coordinator. The facility’s investigation documented that the resident had previously told CNA A on an earlier date that she did not like her roommate because the roommate had hit her in the past. During interview, CNA A confirmed that, while providing care a few weeks prior, the resident reported that her roommate had hit her at some point in the past. CNA A did not ask when the incident occurred or obtain further details, and she did not report the allegation to the abuse coordinator or other facility leadership at that time. CNA A stated she took the report lightly because the resident was talking about other topics and laughing, and because the resident said she had already told other CNAs when it happened. CNA A acknowledged that she recognized the administrator as the abuse coordinator but chose not to report the allegation, believing it was a past event and that the resident did not appear upset. The facility’s written policy on abuse, neglect, exploitation, and misappropriation required that any suspicion of abuse or related violations be reported immediately to the administrator and appropriate officials, defining “immediately” as within two hours for allegations involving abuse resulting in serious bodily injury and within 24 hours for allegations that do not involve abuse or do not result in serious bodily injury. The failure of CNA A to report the resident’s allegation in accordance with this policy led to the cited deficiency for not ensuring that all alleged violations involving abuse and neglect were reported immediately, but no later than 24 hours.
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