Failure to Timely Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to the state survey agency for one resident and did not timely report an allegation of abuse or submit the results of the investigation for another resident. In the first case, a resident with schizoaffective disorder and intact cognition accused a social services staff member of stealing a $1,400 check upon admission. The allegation was documented in the resident's progress notes, but the social services staff did not report the claim to the Administrator, citing a lack of evidence that the resident had a check. The Administrator confirmed that no self-report was made to the state survey agency, as she believed there was no actual property missing. The Director of Nursing was also not notified of the allegation and stated that she would have expected staff to report such claims for investigation and subsequent reporting to the state agency. In the second case, another resident with schizoaffective disorder and type 2 diabetes, and with intact cognition, was involved in an incident where a CNA threw juice on the resident after the resident threw juice at the CNA. The CNA also gestured with a disinfectant spray bottle and made a confrontational statement to the resident. The incident was documented, and the CNA was suspended pending investigation. The facility notified the state survey agency of the abuse allegation, but there was no evidence that the required five-day investigation report was submitted. The Assistant Administrator, who investigated the incident, could not recall if the final report was sent to the state agency. Interviews with facility staff revealed inconsistent understanding and application of reporting requirements. The Administrator and Director of Nursing described processes that involved verifying allegations before reporting, rather than immediately reporting all allegations as required by policy. Staff interviews indicated a lack of clarity about when and how to escalate allegations of abuse or misappropriation, leading to failures in timely and complete reporting to the appropriate authorities.