Failure to Timely Report Alleged Physical Abuse to State Survey Agency
Penalty
Summary
The facility failed to follow its policy and procedures for timely reporting of a reasonable suspicion of a crime, specifically regarding an allegation of physical abuse. An incident occurred in which one resident, who had a history of cerebral infarction with hemiplegia, hemiparesis, and dementia, was struck in the face by a roommate, resulting in facial cuts and a bleeding nose. The resident was noted to have severely impaired cognition and was dependent on staff for most activities of daily living. The incident was documented in the resident's records, and the physician was notified, resulting in the resident being transferred to a hospital for further evaluation and treatment. The facility's internal documentation indicated that the incident occurred in the late afternoon, with the nurse providing first aid and notifying the DON approximately 20 minutes after the event. The DON received the initial call at 5:45 p.m., and the facility's policy required that such allegations involving abuse be reported to the State Survey Agency (SSA) within two hours. However, the actual report to the SSA was sent at 7:52 p.m., which was seven minutes past the required two-hour window. This delay in reporting the alleged abuse resulted in a late notification to the SSA, which in turn delayed an onsite inspection to ensure the safety of other residents. The facility's policy, last reviewed in February 2025, clearly stated the requirement for immediate reporting, but the facility did not meet this standard in this instance.