Failure to Timely Report Alleged Abuse and Resident-to-Resident Incidents
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or theft in a timely manner as required by regulatory guidelines for three separate incidents involving multiple residents and a staff member. In the first incident, a resident with severe cognitive impairment and a history of falls was knocked down by another resident in a wheelchair, resulting in a large hematoma to the back of her head and a complaint of headache. Documentation showed that staff had previously observed the resident in the wheelchair behaving unsafely and nearly injuring others, but the care plan lacked sufficient interventions to address this risk. The incident was not reported to authorities prior to the following day, despite staff witnessing the event and suspecting it may have been intentional. In the second incident, a staff member was alleged to have grabbed a resident with severe cognitive impairment by the wrists and pulled her in an aggressive manner, causing the resident distress. The staff member who witnessed the event reported it to a nurse, but the facility had no documentation of this report or evidence that the allegation was reported to the appropriate authorities as of the time of the survey. Interviews with facility leadership confirmed that such allegations should be reported, but there was no record of timely reporting or investigation. A third incident involved a resident with a history of sexually inappropriate behaviors who was witnessed touching another cognitively impaired resident on the shoulders and chest/breast area. Staff immediately separated the residents and assessed them, and the incident was reported to the state agency the following day. However, facility policy required that such allegations be reported immediately, but not later than two hours after the event if abuse or serious bodily injury was involved. The delay in reporting, as well as the lack of timely documentation and investigation in the other incidents, constituted a failure to follow regulatory requirements for reporting suspected abuse, neglect, or theft.