Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of abuse involving one resident with severe cognitive impairment within the required two-hour timeframe to the administrator and the Department of Health and Senior Services (DHSS). The resident was found with a black eye and bruising to the shoulders, and staff documented that the resident stated someone had hit them. Although the physician and Director of Nursing (DON) were notified, there was no documentation that the allegation was reported to DHSS as required by facility policy and federal regulations. Interviews revealed that an LPN informed the DON about the resident's injuries and the resident's statement, and specifically asked if the incident was reportable to the state. The DON responded that it was not reportable and planned to speak with the resident. Further interviews with nursing staff and the administrator confirmed that the facility's policy is to report all allegations of abuse within two hours, but the incident was not reported because the DON and administrator claimed they were not made aware of the abuse allegations documented in the nurse's notes. As a result, the required notification to the state agency did not occur.