Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
On 05/05/25, facility administration was made aware of an allegation of physical abuse involving a resident and two staff members, the Director of Nurses (DON) and a Certified Nurse Aide (CNA). The incident, which occurred on 05/01/25, involved the DON and CNA physically restraining the resident, searching their pockets, and removing personal items after the resident was found with a bottle of prescription medication. The resident, who had a history of alcohol dependence, opioid abuse, major depressive disorder, and post-traumatic stress disorder, was described as alert and oriented, with an activated Health Care Proxy prior to admission. The incident was reported to the administrator both verbally and in writing by the Substance Use Disorder (SUD) Counselor on 05/05/25. Despite facility policy requiring that all allegations of abuse be reported to the state agency within two hours, the allegation was not reported to the Department of Public Health (DPH) until 05/11/25, six days after the administration was notified. The delay occurred because the current DON misunderstood the reporting requirements, believing she had five days to submit the allegation. The failure to report the suspected abuse within the required timeframe constituted a deficiency in the facility's compliance with abuse reporting regulations.