Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident and a visitor was reported to the appropriate authorities within the required 2-hour timeframe. On the evening of 7/1/25, a resident became verbally aggressive and pushed a visitor, who then pushed the resident in response. Staff intervened and calmed the situation. The incident was documented in the facility's records, and the primary care clinician was notified the same evening. However, the initial report to the state department was not faxed until the following day, more than 2 hours after the incident occurred and was recognized as a potential abuse situation. Interviews with facility staff, including licensed nurses and the Director of Nursing (DON), confirmed awareness of the requirement to report abuse allegations within 2 hours. The DON stated that the delay in reporting was due to not recognizing the incident as a reportable event at the time. Review of facility policy and federal regulations further confirmed the obligation to immediately report all suspected abuse, neglect, or mistreatment. The failure to report the incident in a timely manner constituted noncompliance with both facility policy and federal requirements.