Failure to Timely Identify and Report Alleged Abuse
Penalty
Summary
A resident with hemiplegia, muscle weakness, and difficulty walking was admitted to the facility and required assistance with personal care. On the morning of 04/21/2025, the resident reported to a Speech Language Pathologist (SLP) that a staff member had refused to give them their bed remote control and pushed them on the shoulder the previous night, expressing that the staff member appeared angry. The SLP relayed the allegation to their supervisor and documented it on a grievance form, which was then placed in a grievance box near the social services office. The facility's incident report log showed that the allegation of abuse was not logged until 04/22/2025, and the State Agency was notified approximately 33 hours after the resident initially reported the incident. The Director of Nursing Services (DNS) stated they were unaware of the delay, and the Administrator acknowledged that the allegation should have been reported to the State Agency within 2 hours, rather than being handled solely through the grievance process. This delay in identifying and reporting the abuse allegation resulted in a failure to meet required reporting timeframes.