Failure to Timely Report Witnessed Staff-to-Resident Abuse and Submit Required Investigation
Penalty
Summary
The deficiency involves the facility’s failure to immediately report a witnessed incident of staff-to-resident abuse to the State Agency, law enforcement, and the Administrator, and to timely submit the required 5‑day investigative report. A resident with traumatic brain injury, anxiety, restlessness, agitation, and severe cognitive impairment had documented verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others. On the morning in question, the resident became agitated during incontinence care, attempted to spit at a CNA, and the CNA responded by forcefully pushing the resident’s face with their hands, which was witnessed by another CNA who recognized this as abuse and told the staff member to leave the room. Following the incident, the resident reported that staff had yelled at and disrespected them and had scratched their face twice. An LPN, who entered the room after hearing the resident scream, observed redness and scratches on the resident’s face. The resident was later physically assessed by the Assistant Director of Nursing, who documented multiple abrasions and redness on various areas of the resident’s face, including below both eyes, the right cheek, the tip of the nose, the left eyebrow, above the upper lip, and a scratch extending from the bottom right lip to the chin. Based on interviews, record review, witness statements, and the internal investigation, the facility determined that the resident sustained multiple facial skin alterations related to physical contact made by the CNA. Despite facility policy requiring all allegations of abuse to be reported immediately, but no later than two hours after the allegation, staff did not promptly notify facility leadership or external authorities. The CNA who witnessed the abuse stated they reported the incident to the Assistant Director of Nursing when that person arrived around 8:00 a.m., but the Assistant Director of Nursing reported not being notified until between 11:30 a.m. and 12:00 p.m. The night-shift RN Supervisor was never notified. The Administrator and DON were first made aware around 12:30 p.m., approximately five hours after the 7:00 a.m. incident, and law enforcement was called at about 1:10 p.m. The required 5‑day Nursing Home Investigative Report was not submitted to the State Agency until 12 days after the incident, well beyond the required timeframe, resulting in noncompliance with reporting requirements under F600 and F656.
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