Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency as required by federal and state regulations. Specifically, a resident with a history of atrial fibrillation, deep vein thrombosis, and rhabdomyolysis reported to their family that two certified nurse aides entered their room early in the morning and insisted on providing incontinence care despite the resident's refusal, and the resident felt they were manhandled during the process. The family relayed this complaint to the facility administrator, who initiated an internal investigation and interviewed the involved staff and resident. Despite the facility's policy requiring immediate reporting of such allegations to the Department of Health, the incident was not reported to the State Survey Agency. The Director of Nursing and the Administrator both acknowledged that the incident was not reported, with the Administrator stating that they chose to conduct their own investigation and did not believe the incident constituted abuse. The failure to report the allegation as required constituted a deficiency in the facility's abuse prevention and reporting procedures.