Failure to Timely Report Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency as required under CFR 483.12(c)(1). An incident occurred in which a CNA was witnessed striking a resident on the shoulder and making a derogatory comment about the resident's incontinence. The incident was witnessed by another CNA, who reported it to the nurse on duty at the time, but facility leadership was not made aware of the incident until over a month later. Upon learning of the allegation, the Director of Nursing reported the incident to Adult Protective Services (APS) within the required two-hour timeframe but did not notify the State Agency at that time. The initial report to the State Agency was not submitted, and the final report was sent several days later to an incorrect email address that was not monitored for such reports. As a result, the State Agency was not made aware of the abuse allegation until it was reported by the Office of Long-Term Care Ombudsman. The facility's own policy required immediate reporting of such allegations to both the Administrator and the State Survey Agency, but this procedure was not followed, resulting in a delay in the State Agency's awareness and investigation of the incident.