Failure to Timely Report Allegations of Abuse and Resident-to-Resident Altercation
Penalty
Summary
Facility staff failed to report an allegation of abuse in a timely manner to the State Agency. In one instance, a resident became agitated and accused staff of stealing marijuana, which is not permitted in the facility. The nurse documented the resident's allegation in the medical record, the 24-hour report, and verbally reported it to the oncoming nurse and the nursing supervisor. However, the allegation was not reported to administration or the State Agency, and the Clinical Services Director later confirmed that the incident was not reported as required. In a separate incident, one resident struck another on the head with a cane, resulting in a laceration. The facility's investigation did not include documentation of when the incident was reported to the Office of Health Care Quality (OHCQ) or when the final report was sent. The Nursing Home Administrator was unable to provide documentation of the reporting, as email confirmations had been deleted and were unavailable for review by the surveyor.