Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment were reported immediately or within the required two-hour timeframe for one resident. A resident with schizoaffective disorder, diabetes, and hypertension, who had a history of verbal aggression and moderate cognitive impairment, alleged that a staff member threw a blanket at her face and told her to "shut the hell up." The incident was reported by the resident to a restorative care partner (RCP), who then informed an LVN. The LVN subsequently reported the allegation to the Social Worker, but none of these staff members reported the incident directly to the Abuse Coordinator (EDO) as required by facility policy. Interviews and record reviews revealed that the LVN and Social Worker did not recognize the incident as an abuse allegation and failed to notify the Abuse Coordinator immediately. The LVN stated she did not report the incident to the EDO because the EDO was not present in the facility at the time, and instead reported it to the Social Worker. The Social Worker also did not report the allegation to the EDO, stating she misunderstood the nature of the report and did not realize it was an abuse allegation until later. The delay in reporting resulted in the Abuse Coordinator learning of the incident approximately three hours after the initial allegation was made to staff. Documentation confirmed that the facility's policy required all events involving allegations of abuse to be reported immediately or within two hours. The failure of multiple staff members to follow this policy led to a delay in the investigation and intervention. The resident involved was not injured and did not express fear of living in the facility, but the delay in reporting the allegation constituted a deficiency in the facility's abuse reporting procedures.