Failure to Timely Report Alleged Abuse, Neglect, and Misappropriation
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, or within the required timeframes, to the administrator and appropriate authorities. Specifically, there were delays in reporting incidents involving three residents. In one case, two CNAs attempted to use a resident's debit card at an ATM after receiving it from another resident, but the incident was not reported to the administrator or state agency in a timely manner. The resident whose card was used had moderate cognitive impairment and was unaware that his card was being given to others or used for unauthorized transactions. Interviews revealed that staff and other residents were aware of ongoing issues with the resident's finances, but these concerns were not promptly reported as required. In another incident, a resident-to-resident altercation occurred in which one resident with severe cognitive impairment was struck in the head multiple times by another resident known to have aggressive behaviors. The CNA who witnessed the event reported it to two nurses, but neither nurse reported the incident to the administrator immediately. The administrator only became aware of the altercation several days later, after which the required assessments and reporting were initiated. Interviews with staff indicated confusion or lack of knowledge regarding the proper reporting procedures, with some staff assuming others had reported the incident or not understanding the steps required. Record reviews and staff interviews confirmed that the facility's policies required immediate reporting of abuse, neglect, exploitation, and misappropriation of property, but these procedures were not followed in the cited incidents. The failure to report these events in a timely manner resulted in delayed investigations and assessments, and the facility did not meet regulatory requirements for prompt notification to the administrator and state authorities.