Failure to Timely Report Alleged Abuse and Investigation Results
Penalty
Summary
Facility staff failed to report an allegation of abuse involving a resident within the required 2-hour timeframe and did not submit the results of the investigation to the State Survey Agency within 5 working days, as mandated by regulation. The incident began when a resident reported to a surveyor that a night shift Geriatric Nursing Assistant (GNA) was rough while providing care and made an inappropriate comment. The resident stated that this concern was reported to the night nurse. However, the Unit Manager (UM) was not aware of the allegation until informed by the surveyor and subsequently indicated she would follow up. Further interviews revealed that neither the initial self-report nor the final investigation report was submitted to the Office of Health Care Quality (OHCQ) as required. The DON confirmed that the facility did not report the allegation within the specified timeframes, citing the resident's later statement that the GNA's actions were not intentional. A review of facility records corroborated that the required reports were not made to the appropriate agencies, and no additional information was provided by facility leadership to validate that reporting occurred.