Failure to Timely Report Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to report allegations of abuse and misappropriation in a timely and complete manner for two residents. In the first case, a resident reported that a man had entered his room and physically assaulted him. The allegation was reported to the Director of Nursing (DON) and the State Agency was notified via fax, but there was no documentation that law enforcement or Adult Protective Services (APS) were contacted. Both the current and previous administrators, as well as the previous DON, confirmed that notifications to law enforcement and APS were not made, and these actions were not documented on the required forms. In the second case, a resident alleged that her morning pain medication was not administered, which was later substantiated as misappropriation by a nurse who was subsequently terminated. The initial allegation report was faxed to the State Agency and local law enforcement was notified, but this was not done within the required time frame. There was also no documentation that APS was notified regarding the misappropriation. Interviews with the previous administrator and DON revealed uncertainty about who was responsible for contacting APS and law enforcement, and the DON was unable to recall the regulatory time frames for reporting such incidents. Throughout both incidents, there was a lack of clarity and follow-through regarding the facility's internal processes for reporting abuse and misappropriation allegations. Staff interviews indicated confusion about roles and responsibilities for making required notifications, and documentation was incomplete or missing for critical steps in the reporting process. The required notifications to law enforcement and APS were either not made or not documented, resulting in a failure to meet regulatory requirements for timely and complete reporting.