Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin, were reported immediately, but no later than two hours after the allegation was made. Specifically, a resident who was dependent for care, had a tracheostomy with mechanical ventilation, and was on a restricted diet, accused a respiratory therapist (RT) of yelling at her when she requested a larger cup of ice. The RT documented the resident's allegation in the progress notes but did not report the incident to the Administrator, who serves as the abuse and neglect coordinator. The RT stated she informed her supervisor that the resident was not happy but did not mention the specific allegation of yelling. The supervisor confirmed that he was only told about the resident's dissatisfaction with the ice, not about any abuse allegation. The incident was not reported to the Administrator or the state agency until two days later, when the administrative team reviewed the progress notes and discovered the documentation of the resident's allegation. At the time of the incident, the resident was sometimes understood and sometimes understood others, with a BIMS score indicating the interview could not be completed. The resident later denied any abuse or issues with staff during an interview. The facility's policy required immediate reporting of all allegations of abuse, neglect, or mistreatment to the Administrator, but this protocol was not followed in this case, resulting in a delay in reporting the allegation to the appropriate authorities.