Failure to Timely Report Suspected Inappropriate Restraint Use
Penalty
Summary
The facility failed to report a suspected incident of inappropriate restraint use involving a resident with dementia and severe cognitive impairment in a timely manner, as required by policy and state law. On the morning of 05/06/25, staff discovered the resident in a wheelchair with a sheet tied around their waist and secured to the wheelchair, which was immediately recognized as a restraint. The sheet was removed, and the resident was assessed with no injuries or distress noted. The incident was promptly reported up the chain of command, from the CNA to the ADON and then to the DON. Despite the facility's policy requiring immediate reporting of suspected abuse, neglect, or inappropriate restraint to the Department of Public Health (DPH), the DON did not report the incident to DPH until almost a week later, on 05/12/25. Interviews confirmed that the DON was aware of the incident on the day it occurred but failed to make the required timely report. The delay in reporting was not explained by facility leadership, and the event was only documented in the Health Care Facility Reporting System several days after the initial discovery.