Failure to Timely Report Allegations of Abuse to State Authorities
Penalty
Summary
The facility failed to ensure that all allegations of possible abuse were reported immediately to management and within two hours to the state licensing agency, as required by both facility policy and federal regulations. Specifically, two separate allegations of abuse made by a resident were not reported to the Department of Health and Senior Services (DHSS) in a timely manner. In both instances, the Social Services Director (SSD) and other staff became aware of the allegations but did not document or ensure notification to facility administration or DHSS as required. The resident involved had a complex medical history, including dementia, major depressive disorder with psychotic symptoms, anxiety disorder, PTSD, and physical limitations requiring substantial assistance with activities of daily living. The resident reported to the SSD that two staff members were abusing them and claimed to have bruising, but no bruising was found upon assessment by the SSD and the charge nurse. On another occasion, the resident made further allegations of abuse in a public setting, but again, there was no documentation of notification to administration or DHSS. Interviews with facility staff revealed inconsistent understanding of the reporting requirements, with some staff unsure of the exact timeframes or whether all allegations, regardless of perceived validity, should be reported to the state. The Director of Nursing and Administrator confirmed that the two incidents were not reported to the state, and there was a lack of clear documentation and follow-through on the required reporting process for abuse allegations.