Failure to Timely Report Alleged Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to ensure timely reporting of alleged abuse, neglect, exploitation, or mistreatment of residents to the appropriate authorities, as required. Multiple residents reported incidents of staff being rough, making hurtful statements, refusing care, and other forms of mistreatment. In several cases, residents reported these concerns to staff or surveyors, but there was no documented evidence that the facility initiated timely investigations or reported the allegations to the Office of Health Care Quality (OHCQ) within the required timeframes. For example, two residents alleged that a nurse was rough and had a poor attitude, but the concerns were not reported to OHCQ, and there was no documentation of a timely investigation. Another resident reported that a GNA made derogatory comments about their weight and delayed providing care, but these incidents were not reported as abuse or neglect to OHCQ, and the actions taken were only documented as customer service issues. Additionally, the facility failed to report an incident of alleged theft in a timely manner. A resident's cellphone went missing, and although staff were notified on the day of the incident, the report to OHCQ was not made within the required 24-hour period. In another case, a resident alleged being pushed into bed by a GNA, but the initial self-report to OHCQ was not made within the mandated 2-hour window. Furthermore, a resident reported ongoing issues with a roommate to a GNA, but the allegation was not reported to the state agency, and the facility only addressed the issue internally by arranging a room change. Interviews with facility leadership, including the DON and NHA, revealed a lack of consistent understanding and execution of reporting requirements. In several instances, staff acknowledged that incidents were not reported as abuse or neglect, and documentation was either lacking or delayed. The facility's failure to recognize, document, and report these allegations in a timely manner resulted in noncompliance with regulatory requirements for reporting suspected abuse, neglect, or theft.