Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to timely submit an initial abuse report to the state agency within the required two-hour window after an incident involving a resident and a staff member. The incident occurred in the early morning hours when a resident, who is cognitively intact and uses a manual wheelchair, had a verbal altercation with a receptionist. During the disagreement, the staff member directed derogatory and abusive language toward the resident, which was witnessed by multiple staff members, including two LPNs and a CNA. Witness statements confirm that the staff member told the resident to 'shut up b****,' and both parties exchanged curse words. Following the incident, staff attempted to notify the facility's administrator, who serves as the abuse coordinator, but were unable to reach them due to a religious holiday. The staff then attempted to contact the DON, who also missed the initial call. Eventually, the DON was informed of the incident close to 7:00 am, several hours after the event. The preliminary abuse report was submitted to the state agency at 8:33 am, which exceeded the two-hour reporting requirement outlined in both facility policy and state regulations. The resident involved had significant medical conditions, including paraplegia, multiple stage 4 pressure ulcers, chronic osteomyelitis, and other complex diagnoses, but was assessed as cognitively intact. The facility's own abuse prevention policy requires immediate reporting of abuse allegations to the administrator or designated personnel and mandates that such incidents be reported to the state agency within two hours. Despite these requirements, the delay in internal communication and subsequent reporting resulted in noncompliance with regulatory timelines.