Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to submit an initial report of an allegation of staff-to-resident abuse to the State Survey Agency (SSA) within the required two-hour timeframe for one resident. According to facility policy, all alleged violations involving abuse must be reported immediately, but not later than two hours after the allegation is made if the event involves abuse or results in serious bodily injury. In this case, a resident with severe cognitive impairment, as indicated by a BIMS score of 7 out of 15, reported that a Certified Resident Care Aide (CRCA) made an inappropriate hand gesture towards them. The incident was reported to the Assistant Director of Health Services (ADHS), who then notified the Director of Health Services (DHS) and the Executive Director (ED) in a timely manner. Despite prompt internal notification, the facility did not submit the initial report to the SSA within the required two-hour window. The report was first attempted via fax, but the transmission failed because it was sent to a telephone number instead of a fax line. The ED was unaware that the fax had not been successfully transmitted. The report was eventually submitted via email, but this occurred more than two hours after the initial allegation was made. Interviews with staff confirmed awareness of the reporting requirements, but the delay was due to the unsuccessful fax attempt and lack of follow-up to ensure receipt by the SSA.