Inconsistent Staff Training on Abuse Reporting Timelines
Penalty
Summary
The facility failed to ensure that staff training on abuse reporting was consistent with federal reporting guidelines. During interviews and record reviews, it was found that the lesson plan used for staff education indicated that allegations of abuse were to be reported to the State Agency within 24 hours unless the allegation involved injury. Both the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that the lesson plan was based on state guidance and facility policy, but neither was certain of the specific federal requirements. The DON stated that the lesson plan was reviewed and approved for staff education, and the DSD acknowledged the importance of timely reporting to ensure resident safety. Further review of facility policies and the All Facilities Letter (AFL) 21-26 revealed that federal guidelines require all allegations of abuse to be reported to the State Agency within two hours, not 24 hours as taught in the lesson plan. The Administrator (ADM) also stated that the facility's policy was to report resident-to-resident altercations within two hours, and the facility's policy and procedure documents referenced compliance with both state and federal regulations. However, the training provided to staff did not align with these federal requirements, creating a risk of delayed reporting and investigation of abuse allegations.