Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report a potential allegation of abuse involving a resident with dementia and diabetes mellitus, who was assessed as having moderate cognitive impairment and was largely independent in activities of daily living. On the date in question, the resident reported to the Director of Social Services that a nurse entered their room, threw a shopping bag at them, and yelled at them, which left the resident upset and angry. The incident was documented as a grievance, and the Director of Social Services met with both the resident and the nurse, after which the nurse apologized. The grievance was signed by both the Director of Social Services and the Administrator on the same day. Despite the facility's policy requiring that any complaint, observation, or suspicion of abuse be thoroughly investigated and reported to the Department of Public Health and local law enforcement within two hours, there was no evidence that the incident was reported to the appropriate authorities at the time. The Administrator stated that he did not consider the incident to be abuse, viewing it instead as a customer service issue, and therefore did not report it as required. A review of the Health Care Facility Reporting System confirmed that no report was submitted for the incident until much later.