Delayed Reporting of Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident within the required timeframe during a Recertification and Complaint Survey. On January 29, 2025, at approximately 5:30 AM, a physical altercation occurred between two residents, where one resident was accused of hitting another in the face with a nebulizer machine. The incident resulted in the injured resident having redness, swelling, and a superficial cut on the face. The facility's Administrator was informed of the incident at 5:55 AM but did not report it to the New York State Department of Health until 2:28 PM, which exceeded the mandated two-hour reporting window for incidents involving potential abuse. The facility's policy on abuse prohibition requires that any suspected abuse be reported promptly, especially if it involves serious bodily injury. Despite the policy, the Administrator believed the incident was a peer-to-peer altercation and did not meet the criteria for abuse, thus assuming a 24-hour reporting window was applicable. This misinterpretation led to a delay in reporting the incident to the state agency, resulting in a deficiency citation for failing to adhere to the required reporting timeline.
Plan Of Correction
Plan of Correction: Approved April 1, 2025 I. Immediate Action a. Administrator was re-educated regarding reporting guidelines and timeliness of reporting abuse by facility’s regional administrator. II. Identification a. Administrator reviewed reporting guidelines. b. The facility respectfully states that identified issue has been corrected. III. Systemic Changes a. Administrator and DON reviewed Abuse Prohibition policy on 3/7/25 and found it to be compliant. IV. Monitoring a. Administrator developed an audit tool to ensure any alleged violations involving abuse, neglect, exploitation or mistreatment are reported in a timely manner. b. Audit will be conducted monthly x 12 months. c. All negative findings will be immediately addressed to DOH. All audit findings will be presented to the QA committee quarterly by the Administrator. V. Responsibility a. Administrator is responsible to ensure correction of deficiency.