Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Survey Agency (SSA) within the required timeframe for one resident. According to the facility's policy, all personnel are required to promptly report any incident or suspected incident of resident abuse, including injuries of unknown source. In this case, a resident with multiple diagnoses, including emphysema, chronic pulmonary edema, chronic obstructive pulmonary disease, hemiplegia, dementia, and hypertension, reported that a CNA had shoved a pillow behind her head. The incident occurred on 1/27/2025 but was not reported to the state agency until 1/28/2025. The Director of Nursing (DON) acknowledged responsibility for state reportables and stated that the incident was initially reported to her as rough handling. The Ombudsman visited the facility the following day and informed the Administrator that the incident should be reported as abuse. Law enforcement was also involved after the resident requested to make an assault charge. The delay in reporting the incident to the SSA did not comply with the facility's abuse reporting policy.