Failure to Timely Report Allegations of Abuse to State Survey Agency
Penalty
Summary
The facility failed to timely report allegations of physical and/or emotional abuse to the State Survey Agency as required by policy and regulation. In one instance, a resident with rheumatoid arthritis, chronic pain syndrome, and fibromyalgia, who was cognitively intact, reported to the DON that night shift staff were rough when repositioning them. The DON treated this as a care grievance rather than an abuse allegation, due to the resident's history of pain, and did not report it as abuse. It was only after the resident's family raised concerns to hospital staff days later that the facility reported the allegation to the State Survey Agency. In another case, a resident with Alzheimer's disease and dementia was struck on the head with an eyeglass case by another resident with severe cognitive impairment. The incident was documented, and the physician, family, and management were notified, but the facility did not report the physical abuse allegation to the State Survey Agency. Interviews revealed that staff and management were unclear about reporting requirements, particularly in cases involving altercations between cognitively impaired residents. Facility policy required immediate reporting of all alleged violations to the Administrator, state agency, and other authorities within specified timeframes. Despite this, the facility did not report three separate abuse allegations involving three residents to the State Survey Agency as required. Staff interviews confirmed a lack of understanding and inconsistent application of reporting protocols, contributing to the deficiency.