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F0609
D

Failure to Timely Report Results of Abuse Investigation

Honolulu, Hawaii Survey Completed on 04-25-2025

Penalty

Fine: $8,278
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report the results of an allegation of staff-to-resident abuse within five working days to the State Agency, as required by regulation. The incident involved a resident who expressed emotional distress and dissatisfaction with the care provided by a CNA, as reported by the resident's daughter to the head nurse. The resident was described as emotional and crying, stating concerns about how he was treated and expressing a desire to go home if the situation did not improve. The head nurse documented the resident's account, which included the CNA not providing her name and appearing angry while assisting the resident. Despite the initial event report being submitted to the State Agency, the facility administrator confirmed that the investigation into the CNA's conduct had not been completed, and the final report had not been sent to the Office of Health Care Assurance within the required five-day timeframe. The administrator stated that the investigation was pending due to reliance on a third-party law firm, which had not yet conducted interviews or completed the investigation, even though more than two months had passed since the incident. This delay was in direct violation of both facility policy and federal regulations regarding timely reporting and investigation of abuse allegations.

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