Failure to Timely Report Suspected Abuse to State Agency
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported within the required timeframes. Specifically, an incident was observed in which a certified nursing assistant (CNA) was seen kissing a male resident with chronic systolic heart failure, epilepsy, and chronic obstructive pulmonary disease. The incident occurred late in the evening and was immediately reported by another CNA to the Director of Nursing (DON), who then notified the administrator. Despite this, the administrator did not report the suspected abuse to the State Survey Agency (HHSC) within the mandated two-hour window. Instead, the report was made the following afternoon, well beyond the required timeframe. Interviews and record reviews confirmed that the administrator, who is responsible for reporting suspected abuse or neglect, was informed of the incident on the same night it occurred. The administrator stated that after ensuring the resident felt safe, he waited until the next day to begin the investigation and subsequently reported the incident to HHSC in the afternoon. Facility policy and staff training both required immediate reporting of such incidents, but this protocol was not followed in this case.