Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, to the administrator and to the State Survey Agency, as required by regulation and facility policy. Specifically, two residents made allegations of abuse on the same day, but these were not reported to the appropriate authorities. The first resident, who had a history of paranoid schizophrenia and a BIMS score indicating intact cognition, reported being fondled by a male resident. The incident was documented in the LVN's progress notes, and the DON was informed and spoke with the resident, but the allegation was not reported to the state or further investigated as required. The second resident, who had severe cognitive impairment due to vascular dementia, reported being hit by a female resident. This allegation was also documented in the progress notes, and the resident was subsequently moved to another unit. However, the DON stated she was not aware of this allegation until the survey, and the administrator acknowledged seeing the nursing note but did not receive a direct report. Neither of these incidents was reported to the state agency, as confirmed by a review of the TULIP reporting system. Interviews with facility staff revealed confusion and inconsistency regarding the criteria for reporting abuse allegations. The DON indicated that the resident's BIMS score influenced her decision not to report, and the administrator cited a lack of eyewitnesses and the residents' histories of making unsubstantiated claims as reasons for not reporting. The facility's own policy requires immediate reporting of all allegations or suspicions of abuse, regardless of perceived credibility or witness presence, but this protocol was not followed in these cases.