Failure to Timely Report Abuse Allegations and Investigation Findings
Penalty
Summary
The facility failed to report the findings of a facility-reported incident to the State Survey Agency within the required timeframe for two residents involved in a verbal altercation. The incident occurred in a cottage dining room, where one resident was witnessed yelling at and insulting another. Although both residents were evaluated by staff and one was assessed for behavioral health treatment, the facility did not submit the investigation findings to the State Survey Agency until two days after the required deadline. Interviews with staff revealed confusion and lack of clear assignment regarding who was responsible for submitting follow-up reports, contributing to the delay. Additionally, the facility did not report allegations of resident-to-resident abuse to the State Survey Agency within 24 hours for another incident involving a physical altercation between two residents, resulting in a visible injury. The delay occurred because the incident happened on a weekend, and the responsible staff member did not review or report the event until the following Monday. The facility's own policy requires notification to the State Survey Agency within 24 hours and submission of investigation documentation within five business days, which was not followed in these cases.