Failure to Timely Report Abuse Allegation to State Agency and APS
Penalty
Summary
The facility failed to implement its abuse policy and procedure regarding timely reporting of an abuse allegation involving a resident with osteoporosis and high blood pressure, who was cognitively intact and had adequate hearing and vision. The incident involved a family member visiting the resident, yelling at her, and physically grabbing and twisting her arm, resulting in pain and visible bruising. The abuse allegation was reported to the DON and Administrator, but the required notifications to the State Agency (DHSR) and Adult Protective Services (APS) were not made within the specified 2-hour timeframe as outlined in the facility's policy. The initial report to DHSR was submitted over 20 hours after the facility became aware of the incident, and there was no documentation to support that APS had been notified. Interviews revealed that the Social Service Director (SSD) attempted to report the incident to APS by phone but did not complete the process due to distractions and did not follow up. The SSD also misunderstood the reporting timeframe, believing she had 24 hours to report to DHSR instead of the required 2 hours. The DON, upon returning to the facility, discovered the delay and submitted the report to DHSR but did not complete the APS notification. The Administrator confirmed that staff are expected to follow the abuse reporting policy and procedures, which were not adhered to in this case.