Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported in a timely manner as required by policy and regulations. A cognitively severely impaired resident with multiple diagnoses, including major depressive disorder and hemiparesis, reported being inappropriately touched by another resident who was cognitively intact. The initial incident was documented in a nursing progress note, which stated that a CNA was informed by a resident about the inappropriate touching, and the charge nurse and DON were notified. However, the official report to authorities was not made until several days later, as indicated by the intake and 5-day report dates. Interviews with staff, including CNAs, LPNs, the ADON, and the DON, confirmed that the expectation is for immediate reporting of abuse allegations to the appropriate authorities. The DON acknowledged that the incident documented in the progress note was the same as the one later reported, attributing the delay to an agency nurse not following proper reporting procedures. Facility policy requires that all allegations of abuse, neglect, or misappropriation be reported to state or federal agencies within the required timeframes, which was not followed in this case.