Failure to Timely Report Alleged Abuse, Neglect, and Elopement
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or elopement were reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency (SSA) and Adult Protective Services (APS) for three residents. In the first case, a resident with a history of traumatic brain injury and dementia eloped from the facility and was found by a community member. The CNA who located the resident notified the Director of Nursing (DON) of the elopement, but there was no documentation that APS was notified as required. In the second case, a resident with paranoid schizophrenia, major depressive disorder, and moderate cognitive impairment left the facility with a friend and did not return as expected. The facility made attempts to contact the resident but did not notify law enforcement, APS, or the Ombudsman about the resident's absence. The resident eventually returned to collect belongings and stated he would not be returning, but there was no evidence that the required notifications were made regarding his prolonged absence or potential elopement. In the third case, a resident with Parkinson's disease, schizoaffective disorder, dementia, and other chronic conditions alleged that a CNA had inserted her fingers into the resident's private parts during care. The resident reported the incident to the CNA Coordinator, who did not recall the name of the CNA involved and did not initiate an investigation or report the allegation to the DON or administrator in a timely manner. The CNA Coordinator stated she discussed the situation with the DON, but there was no documentation that the incident was reported to the SSA or APS within the required timeframe. The administrator later acknowledged that the incident was not recognized as an abuse allegation until much later, resulting in a failure to report as required.