Failure to Timely Report Alleged Abuse and Incidents to Authorities
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or theft to the Administrator, State Agency, and Police as required by facility policy for three residents reviewed. In one case, a resident with cerebral palsy and adjustment disorder reported that another resident with Alzheimer's disease grabbed their neck and pushed their wheelchair, leading to a retaliatory act where the first resident ran over the other's feet. This incident was not documented in the care plans or reported to the appropriate authorities until the surveyor brought it to the attention of the Director of Nursing Services (DNS). The DNS admitted to delaying the report to the State Agency and not notifying the police, contrary to facility policy, and was unaware of the incident until informed by the surveyor. Interviews revealed that the social worker and charge nurse were also unaware or did not report the incident, and the resident's representative had not been informed. Another resident with dementia and depression alleged that a nurse aide pushed them into the bathroom, but was unable to identify the aide. The resident reported the incident to their representative, who did not escalate the concern, believing it may have been a misunderstanding. The charge nurse was aware of the resident's ongoing complaints about a mean and bossy aide but did not report these concerns to administration. When the resident later told an RN about being pushed, the RN conducted an informal investigation but did not report the incident to the DNS, nor did she document the event or collect staff statements. The DNS only became aware of the allegation when notified by the surveyor and subsequently delayed reporting to the State Agency. A review of facility documentation, including care plans and nursing notes, failed to show any record of the alleged incidents for the residents involved. The facility's abuse policy requires immediate reporting of any alleged or witnessed abuse to the nursing supervisor, department heads, administrator, police, and state authorities within two hours. The failure to follow these procedures resulted in delayed or absent reporting and documentation of abuse allegations, as well as a lack of timely notification to the appropriate authorities.