Failure to Timely Report and Respond to Allegations of Abuse
Penalty
Summary
The facility failed to timely report allegations of abuse involving three residents out of seven reviewed for abuse. In one incident, a resident with schizoaffective disorder, anxiety, depression, anemia, and PTSD became agitated after being denied a cigarette outside of scheduled smoking times. The resident threw water on an LPN, who, according to multiple staff and resident interviews, retaliated by throwing ice water back on the resident. The resident subsequently called the police. Despite the incident, the LPN was allowed to finish her shift and was not suspended immediately after the allegation was made, and the self-reported incident (SRI) was not submitted until several hours after the event. Another incident involved two residents with significant cognitive and behavioral diagnoses, including dementia, depression, and schizoaffective disorder. During a supervised smoke break, one resident asked another for a light, which was refused, leading to an altercation where one resident attempted to throw a chair and the other responded by hitting. Staff intervened and separated the residents, but the SRI documenting the resident-to-resident altercation was not opened until more than 24 hours after the incident, exceeding the required reporting timeframe. Nursing progress notes did not document the incident for one of the residents involved. Facility policy requires immediate reporting of all allegations of abuse, neglect, exploitation, or misappropriation of resident property to the Administrator or designee and to the state health department, with a maximum reporting window of 24 hours. Interviews with facility leadership confirmed that the incidents were not reported within the required timeframe and that staff involved in the alleged abuse were not suspended immediately as required by policy. These failures resulted in non-compliance with state and federal regulations regarding the timely reporting and handling of abuse allegations.