Failure to Timely Report Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and injuries of unknown origin to the regulatory agency, the Office of Health Care Quality (OHCQ), within the required 2-hour timeframe. Multiple incidents were identified where staff either delayed notifying administration or failed to report to OHCQ promptly after becoming aware of alleged abuse or suspicious injuries. In several cases, staff members, including GNAs, LPNs, and other personnel, did not immediately escalate allegations or observations of potential abuse, resulting in late reporting to both facility administration and the regulatory agency. Specific events included residents and their families alleging rough handling, intimidation, and physical abuse by staff, as well as the discovery of unexplained bruises. In some cases, staff were aware of the incidents but delayed reporting due to fear or uncertainty, while in others, administration was not notified until days later. Documentation reviews revealed that initial reports to OHCQ were consistently submitted well beyond the 2-hour requirement, with some reports sent several hours or even a day after the incident was known to staff. Interviews with facility leadership confirmed these delays and lapses in timely reporting. Additionally, the facility failed to report multiple instances of bruises of unknown origin for a resident with dementia, despite documentation in the medical record. The lack of timely reporting was confirmed through interviews with the DON, ADON, and other staff, who acknowledged the delays and, in some cases, a misunderstanding of the regulatory requirements. The findings were evident for twelve residents reviewed during a complaint survey, highlighting a pattern of noncompliance with mandatory reporting protocols.