Failure to Timely Report Abuse, Neglect, and Misappropriation Incidents
Penalty
Summary
The facility failed to report initial allegations and final summaries of abuse, neglect, or misappropriation of property to the State Survey Agency within the timelines required by federal regulations for multiple residents. In one instance, a potential drug diversion involving resident medications was identified, but the facility delayed reporting the suspicion to the State Survey Agency and local law enforcement, choosing instead to complete an internal medication audit first. The initial report to the State Survey Agency was not made until several weeks after the investigation began, and law enforcement and the board of nursing were not contacted until even later. Additional incidents involved delayed reporting of physical altercations between residents and a case of unexplained bruising. In several cases, the initial reports or final summaries were submitted days after the events occurred, exceeding the required reporting timelines. Interviews with staff confirmed the delays and revealed a lack of immediate action in notifying authorities as required. The facility did not provide timely final summaries for several incidents, and in one case, no further investigation was conducted into the cause of a resident's bruising.