Failure to Timely Report Resident’s Abuse Allegations and Suspected Crime
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime and allegations of abuse in accordance with section 1150B of the Act. A cognitively intact resident with multiple sclerosis, dysarthria, anarthria, and chronic pain reported that during care a CNA flipped her too hard, causing her head to bump the side rail and her glasses to break. She also stated that staff wore ear devices for music, talked about their boyfriends, did not listen to her, and that one staff member swatted her shoulder when she held onto the rail because she felt like she was falling. The resident believed she had to “go with the flow” because she could not move or get up, and she reported these concerns to a CNA and later to an activities staff member. Documentation of one-on-one activity visits showed that on multiple occasions in January the resident shared concerns with an activities assistant, who reported them to management, nursing, the Life Enrichment Director, and the MDS Coordinator. A facility summary indicated that on one date the ADON met with the resident about a CNA spilling urine on her nightgown and causing pain when changing it, and on another date the resident reported that staff were rude, that when they rolled her she felt like she would fall, and that staff would “smack” her for holding on. The resident stated staff still did this and that the person still worked at the facility, although she did not identify who the person was or when it occurred. The Administrator later reported that the resident denied saying she was hit and attributed her arm movements to her disease. Despite these reports, the facility did not notify the state agency within the required timeframe. An incident report later documented that a CNA reported the resident had said someone hit her arm in December. A written statement from a staff member confirmed that the resident had told her in December that someone had done something to her and that the staff member did not report it. Another nurse learned of the allegation during report and, after speaking with the resident about broken glasses and being upset with named CNAs, did not follow up with the CNAs, the DON, or the Administrator. The Administrator acknowledged that the abuse allegation was not reported to the department when first known because she believed it was more of a medical and health issue, and the facility’s self-report log did not show a report submitted at the time of the initial allegation, contrary to the facility’s abuse reporting policy requiring immediate internal reporting and external reporting within 24 hours.
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