Failure to Timely Report Alleged Abuse to State Survey Agency
Penalty
Summary
The facility failed to timely report an allegation of physical abuse involving a resident with dementia and severe cognitive impairment. The resident, who required assistance with activities of daily living due to arthritis and pain risk, reported to a nurse that a Certified Resident Care Associate (CRCA) had hit their hand during a transfer using a stand assist lift. The CRCA stated that the resident complained of pain during the transfer, swatted at her, and she blocked the resident's hand to prevent being hit, but denied any abuse. After the incident, the CRCA ensured the resident's safety, left the room, and was later asked to write a statement and leave the facility. The nurse who responded to the resident's call for help was informed by the resident that the CRCA had hit their hand. The nurse ensured the resident's safety, spoke with the CRCA, and then reported the incident to the Director of Health Services (DHS). The DHS, upon being notified, informed the Executive Director (ED), who was responsible for mandatory reporting and investigation. According to facility policy, all allegations of abuse must be reported to the State Survey Agency (SSA) within two hours of the allegation being made. Despite these procedures, the timeline revealed that the allegation was made to the nurse at 8:20 PM, but the ED did not report the incident to the SSA until 10:48 PM, exceeding the required two-hour reporting window. The ED initially assumed the incident occurred later, but upon investigation, realized the actual time of the allegation was earlier, resulting in a late report to the SSA. This failure to report within the mandated timeframe constituted the deficiency.