Failure to Timely Report Allegation of Staff-to-Resident Abuse to Required Agencies
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of employee-to-resident physical abuse to law enforcement, the State Survey Agency, and Adult Protective Services (APS) within the required time frame. Facility policy required that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, or misappropriation of property be reported immediately, and no later than 2 hours if the allegation involved abuse or serious bodily injury, or within 24 hours if it did not. The policy also specified that the Administrator or designee must notify the State Survey Agency and other appropriate agencies, and notify law enforcement if the incident was reasonably believed to constitute a crime. On the date of the incident, a nurse practitioner (NP) entered the resident’s room and observed the resident wiping water from the floor with a few ice cubes present. The resident told the NP that staff were throwing things at her, such as mashed bananas. The NP did not observe mashed bananas on the resident or that the resident was wet, but she contacted a nurse manager (Nurse #5) so the DON and Administrator could be notified. Nurse #5 reported that she received a call from the NP stating that the resident had thrown a banana at a nurse and alleged that water was thrown back at her, and Nurse #5 then called the DON and Administrator that afternoon. The Administrator stated he requested the Rehabilitation Manager return to the facility to investigate and later received a call indicating the resident was upset but there was no evidence of abuse at that time. The Rehabilitation Manager reported that he returned to the facility, interviewed staff and the resident, and learned that the resident had thrown a banana at a nurse and that a banana and water were thrown on the resident, though the resident did not identify which staff members. The resident’s family member stated she received a call from the resident the same day reporting that a banana and water were thrown on her, and the family member was told later that an investigation was ongoing. An Initial Allegation Report documenting that staff allegedly threw mashed bananas and ice water on the resident was not completed and faxed to the State Survey Agency until two days after the allegation, and law enforcement was notified the same day the report was completed, not on the day of the allegation. APS notification was not documented in either the Initial Allegation Report or the subsequent Investigation Report. The DON later stated she was unaware that the allegation needed to be reported to APS, and the Divisional Director of Nursing acknowledged that the allegation should have been reported on the day it was made and that the report was not submitted timely.
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