Failure to Timely Report Alleged Abuse to Administration and State Agency
Penalty
Summary
A deficiency occurred when an allegation of abuse made by a resident was not reported to facility administration or the State Agency as required. The incident was documented in a nursing progress note by an LPN, who recorded that the resident stated someone on the night shift had kicked them. Despite this documentation, the LPN did not notify the Director of Nursing (DON) or the Administrator directly, nor was there any documentation to verify that the required notification took place at the time of the allegation. The resident involved had a history of hallucinations, anxiety, depression, impaired cognitive function, and was under hospice care for cancer. Despite these conditions, the resident was assessed as cognitively intact according to the most recent Minimum Data Set. The facility's policies, the LPN's job description, and recent in-service training all required immediate reporting of abuse allegations to supervisory staff and the State Agency, but these procedures were not followed in this instance. The failure to report the allegation was only discovered when surveyors brought the progress note to the attention of the Administrator several months later. At that point, the facility initiated an investigation and notified the appropriate authorities, but the initial delay in reporting constituted a violation of the facility's abuse reporting policies and regulatory requirements.