Failure to Timely Report Alleged Abuse and Investigation Results
Penalty
Summary
The facility failed to ensure that all alleged violations related to abuse were reported immediately, but not later than two hours after the allegation was made, to the appropriate officials, including the State Survey Agency. Additionally, the facility did not report the results of the investigations to the State Survey Agency within five working days of the incidents. These failures were identified in three residents reviewed for abuse out of a total survey sample of eight residents. The reporting requirements under this regulation are based on real (clock) time, not business hours. One resident, who had multiple complex medical conditions including acute respiratory failure, congestive heart failure, diabetes, morbid obesity, and moderate cognitive impairment, was involved in an incident where his family alleged that a CNA was rough and rude while assisting him with toileting. The incident was initially reported by the resident to his family, who then reported it to the facility. The facility's Social Services Director completed a grievance form, but the incident was not immediately recognized or reported as abuse. The Administrator initially considered the matter a customer service issue and did not file an abuse report until confronted by the family, resulting in a delay in reporting the allegation to the State Survey Agency. In another incident, two residents were found in a situation involving likely inappropriate sexual behavior. Nursing staff discovered the incident and separated the residents, notifying the Administrator in Training. However, the facility did not submit the required 5-day federal report until several days after the incident, with the Administrator stating that submission within five business days was considered timely according to their practice. The facility's own policy required reporting of abuse allegations within two hours, but this was not followed in these cases.