Failure to Timely Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to report allegations of abuse and misappropriation of property to the State Agency as required by policy and regulation. In one instance, a resident with a history of malignant neoplasm, chronic heart failure, and post-traumatic stress disorder, who was cognitively intact, reported that a nurse aide had exposed herself and engaged in inappropriate behavior. The resident communicated this to another nurse aide, who then reported it to a registered nurse and the facility administrator. Despite these reports, the administrator did not notify the State Agency, dismissing the incident as a hallucination, and the nurse aide in question continued to work, only being removed from the resident's care assignment. Multiple staff interviews confirmed knowledge of the allegation, but no timely report was made to authorities as required by the facility's abuse policy. In another case, two residents with chronic medical and psychiatric conditions reported missing cell phones. One resident reported the missing phone to the Therapeutic Recreation Director, who searched for the phone but did not escalate the issue to the administrator or complete a grievance. The Director of Environmental Services was also informed but did not file a report, assuming the issue had already been addressed. The second resident reported the missing phone to a nurse aide, who searched for the phone but did not report the incident, believing others were already aware. In both cases, the missing property was not reported to the appropriate supervisory staff or the State Agency in a timely manner, as required by facility policy. Interviews with facility leadership, including the Director of Nursing and the administrator, revealed that staff were expected to report such incidents immediately, but this did not occur. The facility's abuse prohibition policy clearly directed staff to report any knowledge of abuse, neglect, or misappropriation of property to supervisors and the State Agency within specified timeframes. Despite this, staff failed to follow reporting protocols, resulting in delayed notification and investigation of the allegations.