Failure to Timely Report Allegations of Abuse, Neglect, and Serious Injury
Penalty
Summary
The facility failed to ensure timely reporting of allegations of abuse, neglect, and serious bodily injury to the State Agency (SA) as required by both facility policy and federal regulations. In seven out of ten Facility Reported Incidents (FRIs) reviewed, initial reports were submitted to the SA outside the mandated time frames. Specific incidents included allegations of verbal abuse by a Certified Nursing Assistant, resident-to-resident physical and sexual abuse, neglect resulting in a fall with a hip fracture, and employee-to-resident physical and verbal abuse. Documentation showed delays ranging from several days to over a week between the occurrence of the incidents and the submission of initial reports to the SA. Facility policy required immediate reporting, but interviews with facility leadership confirmed that the process was not consistently followed. The incidents involved various forms of abuse and neglect, including physical altercations between residents, inappropriate sexual contact, and a fall resulting in serious injury. Progress notes and interviews indicated that staff did not always report incidents to facility leadership immediately, and leadership did not always report to the SA within the required two-hour or 24-hour windows, depending on the severity of the allegation.