Failure to Timely Report Alleged Abuse and Injuries
Penalty
Summary
The facility failed to ensure timely reporting of multiple allegations of abuse, neglect, and injury of unknown origin to the State Agency and the Administrator/Abuse Coordinator, as required by federal regulations and the facility's own policy. In one incident, an LPN witnessed a resident nude from the waist down in another resident's room, sitting on the bed and caressing the other resident's hip and thigh. The LPN immediately reported the incident to the Administrator/Abuse Coordinator, but the Administrator did not report the allegation of sexual abuse to the State Agency until three days later. The Administrator stated that he did not initially perceive the incident as sexual abuse and therefore did not report it within the mandated two-hour timeframe, despite the facility's policy requiring immediate reporting of all abuse allegations. Additional deficiencies were identified in other cases where staff failed to report allegations of abuse or injury within the required timeframe. In one case, an allegation of verbal abuse involving a housekeeper and a resident with severe cognitive impairment was not reported to the Administrator or State Agency until more than 24 hours after the incident occurred. In another case, bruising and a subsequent fracture of a resident's finger, discovered in the morning, was not reported to the State Agency until after X-ray results were obtained later that day, rather than within two hours of discovery. There was also a physical altercation between two residents that resulted in injuries, but the incident was not reported to the Administrator or State Agency within the required timeframe. These failures affected at least four residents sampled for abuse, as determined by the investigation of multiple facility reported incidents and complaints. The survey found that the facility's noncompliance with reporting requirements caused, or was likely to cause, serious injury, harm, impairment, or death to residents, resulting in the citation of Immediate Jeopardy and substandard quality of care under F609 - Reporting of Alleged Violations.