Failure to Timely Report Alleged Abuse, Neglect, and Drug-Related Incidents
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than two hours after the allegation was made, as required by federal and state regulations. Specifically, two residents were involved in separate incidents that were not reported to the state agency or law enforcement as required. In the first case, a male resident with dementia and a history of sexually inappropriate behaviors inappropriately touched a student visitor during an activity. Despite being aware of the incident, the DON and Administrator did not report the event to the state agency, citing uncertainty about the details and lack of clear evidence from camera footage. Interviews with staff and residents revealed ongoing concerns about the resident's sexually inappropriate behaviors, which had been reported to facility leadership but not adequately addressed or reported. In the second case, another male resident with multiple diagnoses, including bipolar disorder and legal blindness, was found exhibiting signs of a drug overdose and was transported to the hospital, where he tested positive for marijuana. Prior to this event, there were documented concerns about the resident bringing drugs into the facility to sell to others, and a 30-day discharge notice had been issued due to non-compliance. Despite these concerns and the positive drug test, the facility did not report the incident to law enforcement or the state agency. Interviews with residents and staff indicated ongoing issues with drug use within the facility, with reports of marijuana and other substances being used during smoke breaks and in resident rooms. The Administrator and DON acknowledged awareness of these issues but did not initiate investigations or report the incidents as required. The facility's policy on abuse prevention requires the investigation and reporting of any allegations of abuse within the required timeframes. However, in both cases, the facility failed to follow established procedures for reporting suspected abuse, neglect, or exploitation. The lack of timely reporting and investigation of these incidents could place residents at risk for continued abuse or harm due to unaddressed allegations.