Delayed Submission of Abuse Investigation Results
Penalty
Summary
The facility failed to ensure that the results of an investigation into an alleged incident involving two residents were reported to the State Survey Agency within the required five working days. The incident involved a loud verbal disagreement between two residents, both with severe cognitive impairment, resulting in one resident being found on the floor with swelling and a laceration to the left eye, and the other resident holding a wheelchair leg rest. The initial report of the incident was made to the Department of Health shortly after the event, but the final investigation results were not submitted until eight days after the incident, exceeding the five-day regulatory requirement. Facility policy required the Director of Nursing or designee to complete the investigation summary and ensure all alleged abuse was reported to the Department of Health and the Administrator. Despite this, the final investigation summary and findings were not submitted within the mandated timeframe. The Director of Nursing acknowledged that the final investigation should have been submitted one day earlier than it was, confirming the delay in reporting as a deficiency.