Failure to Timely Report Allegation of Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the New Jersey Department of Health (NJDOH) within the required two-hour timeframe after becoming aware of the allegation. The incident involved a certified nursing assistant (CNA) who was alleged by a resident's family member to have inappropriately touched the resident during an initial skin evaluation. The family member reported the concern to the Assistant Director of Nursing (ADON) on the day of the resident's discharge, several days after the alleged incident. The resident, who had diagnoses including acute cystitis, sepsis, diabetes, and muscle weakness, was cognitively intact and required significant assistance with mobility and toileting at the time of the incident. Upon receiving the allegation, the Director of Nursing (DON) and ADON immediately interviewed the resident, who denied any inappropriate touching, and subsequently interviewed the CNA and the nurse present during the assessment, both of whom denied the allegation. The facility's investigation concluded that the allegation was unsubstantiated. However, the facility did not report the allegation to the NJDOH within two hours as required by regulation, regardless of the outcome of the internal investigation. Interviews with facility leadership confirmed that all staff are responsible for reporting abuse allegations and that such allegations should be reported to the NJDOH within two hours. The Licensed Nursing Home Administrator (LNHA) acknowledged that the event was not reported, mistakenly believing that if the facility could unsubstantiated the allegation within two hours, reporting was not necessary. This failure to report was contrary to both facility policy and state regulations.