Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident with dementia, epilepsy, and major depressive disorder was properly reported to the State Agency. The resident, who was cognitively intact as indicated by a BIMS score of 15, reported to a nurse that a CNA had pulled her hair during care. This allegation was documented as a grievance, and an internal investigation was initiated, with the grievance marked as resolved several days later. Despite the facility's policy requiring immediate reporting of abuse allegations to the administrator, state agency, and other authorities within specified timeframes, there was no evidence that the incident was self-reported to the State Agency as required. When surveyors requested a list of self-reported incidents from the past ninety days, both the DON and the VP of Health Services stated that there had been no such reports, and a review of state agency records confirmed that no self-report had been submitted for this incident. Interviews with facility staff revealed confusion regarding the documentation and reporting process. The DON claimed to have submitted a report online and provided an email indicating a request for email verification, but there was no documentation confirming that the complaint was finalized and submitted. The VP of Health Services later attributed the omission from the self-report list to an oversight. The facility's failure to ensure timely and proper reporting of the abuse allegation constituted a deficiency.