Delayed Reporting of Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, as required by their policy and federal regulations. The incident involved a resident who expressed a desire to attend a church activity but was allegedly told by a nurse aide that she would be going to bed instead. This incident was reported to a registered nurse the following day, who then informed a social worker. However, the investigation into the alleged abuse did not commence until four days after the incident, and the state regulatory agency was not notified until five days after the incident. The delay in reporting was acknowledged by the Director of Nursing, who noted that the administration was not made aware of the incident until several days after it occurred. The facility's policy mandates immediate reporting of such allegations to the appropriate authorities, but this protocol was not followed in this case. The resident involved was upset and crying when recounting the incident, indicating the emotional impact of the event. The failure to report the incident in a timely manner constitutes a deficiency in the facility's adherence to required procedures for handling allegations of abuse.
Plan Of Correction
1. The facility cannot retro entry of the PB-22 that was not submitted timely for R52. The resident was not assessed at the time of the event due to staff not reporting. 2. The facility has a new Director of Nursing and education provided by the regional nurse/designee on timely reporting of PB-22 submissions. An audit was completed, and no other residents were identified as having similar experience. 3. An audit will be conducted by the NHA/designee via line listing of reportable events weekly x 4 to ensure that any reportable requiring a PB-22 has timely submission of the documentation. All staff completed abuse training in March 2025 which included immediately reporting alleged violations. Abuse training is completed regularly - 2 times a year. 4. Results of the audit will be taken to QAPI for review of findings and further interventions if indicated.