Failure to Timely Report Allegations of Abuse, Neglect, and Misappropriation
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and misappropriation of property to the Office of Health Care Quality (OHCQ) within the required timeframes for multiple residents. In several cases, reports of alleged physical abuse, verbal abuse, and theft were not submitted within the mandated 2-hour window for abuse or 24-hour window for misappropriation. Documentation and interviews confirmed that the initial reports were delayed, with some incidents being reported a day or more after the event, and in one case, the facility could not provide evidence of when the report was submitted. Facility leadership, including the Nursing Home Administrator (NHA) and Director of Nursing (DON), acknowledged these delays during interviews, often noting that they were not employed at the facility at the time of the incidents but confirmed the findings based on available records. Specific incidents included allegations of staff physically and verbally abusing residents, missing narcotic medication, and theft of personal items and money. In one instance, a resident alleged being punched and wrestled by a phlebotomist during a blood draw, while another resident reported being hit by a GNA and threatened with a wheelchair. There were also cases where residents' personal property went missing, and the facility did not notify the regulatory agency promptly. In another case, a resident with cognitive impairment and a history of stroke developed unexplained wrist swelling, and the incident was not reported as required, despite the resident's vulnerability. The facility's investigations often lacked timely documentation, and in some cases, there was no evidence of an investigation or report submission at all. Staff interviews and record reviews consistently revealed that the administration was not made aware of incidents promptly, leading to delays in reporting to OHCQ. The failure to report these incidents within the required timeframes was confirmed by facility leadership during the survey process.