Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency within the required timeframe for one resident. According to facility policy, all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported to the appropriate agencies not later than 2 hours after the allegation is made if it involves abuse or results in serious bodily injury, or within 24 hours if it does not. In this case, a resident with a history of fibromyalgia, depressive episodes, cognitive deficits following a stroke, and insomnia, who was assessed as cognitively intact, reported being grabbed, held down, and forced to take a shot at the end of March. The resident also reported to police that she had been beaten by a nurse, tied up, and had blood drawn. Facility documentation showed that the Administrator or DON were notified of the allegation on April 1, but there was no evidence that the State Agency was notified at that time. The surveyor was made aware of the allegation during an interview with the resident, who displayed a purple discolored area on her right upper arm. The facility staff did not report the allegation to the State Agency until April 16, well after the required reporting timeframe. The delay in reporting was confirmed by the Administrator, who acknowledged that the allegation was not reported as required when it was initially made by the resident.