Failure to Timely Report Suspected Abuse and Staff Knowledge Deficits
Penalty
Summary
Facility staff demonstrated a lack of knowledge regarding the correct abuse reporting guidelines, including whom to report abuse allegations to and the required time frames for reporting. Interviews with both licensed and unlicensed staff revealed inconsistent and incorrect understanding of the reporting process, with several staff members stating that abuse allegations should be reported within 24 hours, rather than the required two-hour window for incidents involving abuse or serious bodily injury. Some staff were also unclear about which agencies needed to be notified, with responses varying between the state, Ombudsman, law enforcement, and the facility administrator. A specific incident was identified in which an allegation of abuse occurred when a certified nursing assistant was observed holding a sheet over a resident's head and pushing her down. The report of suspected dependent adult/elder abuse was not faxed to the Ombudsman and law enforcement until the following day, exceeding the mandated two-hour reporting window. The administrator confirmed that the facility did not meet the required reporting time frame for this incident.