Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to ensure that all allegations of abuse were reported and reported in a timely manner, as required by policy. In one incident, a resident with moderate cognitive impairment and multiple diagnoses, including schizoaffective disorder and major depressive disorder, was found in another resident's room with his penis exposed and was observed touching the other resident's breasts over her clothing. This incident was documented in a nursing progress note, but was not reported as a self-reported incident (SRI) until the following day, after it was discovered during a clinical review meeting. The Director of Nursing confirmed the delay in reporting. In a separate incident, the same resident was observed touching himself in front of another resident, who was rarely understood and had diagnoses including vascular dementia and major depressive disorder. Staff interviews confirmed that the resident had exposed himself to this other resident on more than one occasion. Despite these observations and documentation in the nursing progress notes, there was no SRI filed for these allegations of abuse. The Director of Nursing verified that these incidents were not reported as required by the facility's abuse policy, which mandates immediate reporting to the Administrator and the Department of Health.