Failure to Timely Report Allegations of Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or theft in a timely manner for multiple residents, as evidenced by record review and staff interviews. In several cases, allegations were either not reported to the state agency within the required timeframe or not reported to law enforcement as appropriate. For example, one resident with complex medical needs, including hydrocephalus and chronic kidney disease, reported an incident involving a blood draw that was perceived as abusive. The DON was notified by the resident’s family, but the incident was not reported to the state agency until two days later, exceeding the required reporting window. Another instance involved a cognitively intact resident who reported theft of money to a receptionist, who then informed the DON. The DON initiated an internal investigation and interviewed staff, but the incident was not reported to the state office until the following day, and law enforcement was not notified. Additional cases included residents reporting abuse or missing money to staff, with delays in both internal notification to facility leadership and external reporting to the state agency. In one case, a resident’s allegation of abuse was reported to an LPN, but the NHA was not notified until two days later, and the state agency was not informed until four days after the initial report. Facility policy required allegations to be reported to the administrator within 24 hours and to state agencies as per regulations, which in some cases is within two hours. Interviews with the NHA and DON confirmed awareness of these requirements, but documentation and investigation records showed repeated failures to meet the mandated reporting timelines. These deficiencies were identified for five residents out of fifteen reviewed for abuse allegations.