Failure to Report Substantiated Staff Abuse to State Licensing Authority
Penalty
Summary
The deficiency involves the facility’s failure to follow policies and state law requiring timely reporting of staff-to-resident abuse to the appropriate state licensing authority. Resident #104, who had chronic pain, anxiety, and dementia, was involved in an incident where an LPN (LPN CC) engaged in conduct that the facility later substantiated as verbal and physical abuse. According to the facility-reported incident investigation, the resident was agitated and pacing when LPN CC instructed the resident to go to her room and stay there. The resident refused, approached the LPN, and attempted to strike her. LPN CC then placed the resident’s arms behind her back, physically assisted the resident to her room, and closed the door, during which the resident stated, “stop that hurts.” The facility’s in-depth analysis documented that the LPN did not use de-escalation skills and that her frustration intensified the situation, resulting in verbal and physical abuse. The investigation summary did not document that the facility reported LPN CC to the State Bureau of Professional Licensing, despite the substantiated abuse and the disciplinary action taken against the nurse. During interviews, the Nursing Home Administrator confirmed that she had substantiated the verbal and physical abuse and that the LPN’s employment had been terminated. When asked whether the termination and abuse had been reported to the State Bureau of Professional Licensing, the administrator initially could not recall and later confirmed that no report had been made. She stated that she had completed the reporting form but forgot to fax it, and the report was missed. This failure to report occurred despite state law (Michigan Public Health Code MCL 333.20175) requiring health facilities to report specified disciplinary actions and employment changes related to licensed health professionals within 30 days.
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