Failure to Timely Report Allegations of Abuse and Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse, neglect, or theft, and did not report the results of investigations to the proper authorities as required by policy. In one instance, a cognitively intact resident reported to a nurse aide that they had been mistreated during a recent hospital stay and expressed fear for their safety, showing a bruise on their hand. The aide reported this to the nurse on duty, who then contacted the on-call nurse. However, the incident was not reported to the Director of Nursing (DON) or the Administrator within the required timeframe. The DON and Administrator only became aware of the allegation days later during a morning meeting, well beyond the policy's two-hour reporting requirement for abuse allegations. In another case, a resident-to-resident altercation was witnessed by a nurse aide, where one resident struck another, resulting in minor redness to the face. The incident was reported to the assigned nurse, who checked the injured resident and later reported the event to the DON. However, the report to the DON was delayed by over an hour, and the subsequent report to the state agency was not made within the mandated two-hour window. Staff interviews confirmed that although they had received abuse training and were aware of the immediate reporting requirements, the delay occurred due to being occupied with other duties and a breakdown in communication. Both incidents demonstrate that staff did not follow the facility's policy, which requires immediate reporting of all allegations of abuse, neglect, or misappropriation to the DON or Administrator, and timely notification to state and federal agencies. The failure to report these incidents promptly resulted in non-compliance with regulatory requirements and facility policy, as confirmed by staff and administrative interviews and documentation review.