Deficient Abuse Reporting Policy with Conflicting Timelines
Penalty
Summary
The facility failed to develop and implement a policy for reporting allegations of abuse that was consistent with federal requirements and free of conflicting information. The Resident Protection Plan policy, last revised in February 2023, stated that reports of mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of property, are to be promptly and thoroughly investigated and reported immediately. However, the policy contained conflicting timelines, indicating that if the events involved abuse or resulted in serious bodily injury, the report must be made immediately and no later than two hours after the allegation, but for other events, the report could be made within 24 hours. Additionally, the policy stated that certain findings, such as unexplainable injuries or substantiated abuse, must be reported to the Office of Health Facility Complaints immediately, not to exceed 24 hours, which is inconsistent with the federal requirement for reporting within two hours if abuse or serious bodily injury is involved. During interviews, the administrator confirmed that the current policy was in use and stated that staff were expected to report allegations of abuse immediately to her, with reports of sexual abuse to be made within two hours and all other reports within 24 hours. The administrator also stated that verbal abuse would need to be reported within 24 hours of being made aware of the incident. These statements and the policy itself were not fully aligned with the federal regulation, which requires all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, to be reported immediately, but not later than two hours if the events involve abuse or result in serious bodily injury. This inconsistency had the potential to affect all residents in the facility.