Failure to Timely Report Alleged Physical Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of physical abuse to the state survey agency. A resident with neurocognitive disorder with Lewy bodies dementia, major depressive disorder, and mood disorder was moderately cognitively impaired, required limited assistance with ADLs, and used a wheelchair. The resident’s care plan identified risk for refusing care and not waiting for assistance with transfers, with interventions including assistance of two staff for care and transfers and use of a calm, gentle approach. During provision of incontinent care, the resident became combative and refused care while staff attempted to change a soaked brief and bedding. According to written statements, three NAs entered the resident’s room to provide care. One NA held the resident’s arms so another NA could change the brief, and a third NA assisted in holding the resident’s arms. One NA was alleged to have slapped the resident hard on the arm while using an expletive, and two NAs reported witnessing the slapping. One NA stated she should have reported the incident when it happened, and another NA stated she did not report the incident because she thought the other NA would report it, although they had not discussed reporting. The involved NAs continued to work in the facility on subsequent days because the allegation was not reported at the time of occurrence. The incident was alleged to have occurred several days before it was brought to the attention of the RN Nursing Supervisor, who was notified toward the end of a later shift that an NA had slapped the resident during care. The Nursing Supervisor documented that two NAs confirmed the allegation and that the incident had occurred days earlier, with no noted signs or symptoms of injury. The DNS was later notified via text message and began an investigation, during which statements were obtained and the allegation was ultimately substantiated based on two staff witnesses. The facility’s policy required immediate investigation when there was suspicion or reports of abuse, neglect, or exploitation, but the delay in reporting by staff and the delayed notification to the state survey agency constituted a failure to ensure timely reporting of the abuse allegation.
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