Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe for a resident. The facility's policy mandates that all allegations of abuse, including those of unknown source, must be reported immediately to the Administrator, Director of Nursing, and the applicable State Agency. However, the facility did not adhere to this policy for one resident, identified as Resident R29, who was diagnosed with Trichomoniasis during a routine gynecological exam. The resident, who has severe cognitive impairment as indicated by a BIMS score of 6, mentioned being in a consensual relationship with another resident, but due to her cognitive issues, she was unreliable in determining when the intercourse might have occurred. The clinical record review and staff interviews revealed that the facility did not report the incident involving Resident R29 to the appropriate authorities within the required timeframe. The Nursing Home Administrator and Director of Nursing confirmed this failure during an interview. The resident's medical history includes diagnoses of encephalopathy, alcoholic cirrhosis, depression, and muscle weakness, which contribute to her cognitive impairment. Despite the resident's denial of intercourse, she admitted to physical contact with the other resident, which should have prompted an immediate report according to the facility's policy.
Plan Of Correction
1. Event report was submitted on 2/6/2025. 2. 24-hour report, progress notes, grievance reports will be reviewed at morning clinical meeting to ensure investigation is completed for any incidents, accidents or grievances if warranted. 3. The Interdisciplinary Team will be educated by the Regional Clinical Director on Reporting and investigating allegations of abuse and neglect. 4. Administrator/designee will audit weekly x2, monthly x2 any allegations for proper investigation and reporting. 5. Findings will be submitted to Quality Assurance Performance Improvement Committee.