Failure to Timely Report Alleged Abuse to Administrator and State Agency
Penalty
Summary
The facility failed to ensure that an allegation of physical abuse involving a resident was reported immediately to the facility administrator and the State Survey Agency, as required by policy and federal regulations. The incident involved a resident with diagnoses including dementia, paranoid schizophrenia, and anxiety disorder, who was severely cognitively impaired and required substantial assistance with bed mobility. An agency nurse observed a bruise/skin tear on the resident and expressed suspicion that an agency CNA may have caused the injury. The nurse communicated this suspicion to the Director of Nursing (DON) by phone, who then began an investigation and assessed the resident, noting the injury but no signs of emotional distress or verbalization of harm from the resident. Despite the suspicion of abuse, there was no documentation that the administrator or the State Survey Agency was notified of the allegation as required. The DON instructed the agency nurse to contact the administrator and write a statement, but this was not done. The facility's policies clearly state that all allegations of abuse, including injuries of unknown origin, must be reported immediately to the administrator and appropriate authorities, with "immediately" defined as within two hours for abuse allegations. Interviews confirmed that the administrator was not made aware of the incident in a timely manner and that the required notifications were not completed.