Delayed Reporting of Abuse Investigation Results
Penalty
Summary
The facility failed to report the results of an abuse investigation within the specified timeframes as outlined in their policy. According to the facility's Abuse Prohibition policy, the Administrator or designee is required to report findings of all completed investigations within five working days to the Department of Health. An alleged incident of neglect occurred on September 24, 2024, and the facility began an investigation on September 25, 2024, concluding it on September 26, 2024. However, the investigation results were not submitted to the Department of Health until October 7, 2024, which exceeded the five working day requirement. During an interview, the Nursing Home Administrator explained that the delay was due to the Director of Nursing's absence because of illness, and the expectation was that the Administrator should have submitted the report in her absence.
Plan Of Correction
1. The facility can not retroactively correct cited deficiency. 2. A comprehensive review of the reports submitted from the last three months will be completed to ensure the PB-22 reporting form was submitted within five days. 3. The facility will take further steps to validate the problem does not reoccur by re-educating the Administrator / Designees on FTag 609 with a focus on timely PB22 submissions. 4. Compliance will be monitored by the Director of Nursing/Designee using the Reporting audit through two audits weekly x 3 audits. 5. Results will be reported to the QAA Committee who will determine the need for further audits.