Failure to Timely Report Additional Abuse Allegation
Penalty
Summary
The facility failed to submit an initial report of a staff-to-resident abuse allegation to the state survey agency within the required two-hour timeframe for one resident. According to facility policy, any alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, but not later than two hours after the allegation is made. In this case, a resident with a history of depression, cognitive impairment, and brain cancer reported concerns of physical and sexual abuse involving a CNA and an LPN. The resident initially disclosed physical abuse and later, during a follow-up interview, made an additional allegation of sexual abuse involving the same LPN. Despite the second allegation being made during the follow-up interview, the Assistant Director of Nursing, who was the Abuse Coordinator, did not submit a separate initial report for the new allegation, considering it part of the original incident. The facility's investigation file did not include an initial report for the sexual abuse allegation, and the Administrator confirmed that both allegations were combined into one investigation. Interviews with facility leadership indicated awareness that the initial report should have been sent within two hours, but this protocol was not followed for the second allegation.