Failure to Timely Report Alleged Staff Misconduct Involving Alcohol Use During Resident Outing
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency. Specifically, a staff member was arrested for driving under the influence (DUI) and had alcohol in the facility vehicle while transporting residents during a rafting trip. Additionally, it was alleged that maintenance, activities, and nursing staff consumed alcohol during the outing with residents. The incident was not documented in the medical records of the involved residents, and the State Survey Agency was not notified as required. The residents involved included individuals with significant medical conditions such as dementia, osteoporosis, macular degeneration, chronic pain, cerebral palsy, contracture, muscle weakness, cramp and spasm, major depressive disorder, Lupus, anxiety, and a history of falling. Despite the serious nature of the allegations and the vulnerability of the residents, there was no evidence in their records regarding the incident, and the required reporting procedures were not followed. The facility administrator confirmed that there was a zero-tolerance policy for alcohol and that the incident should have been reported, but acknowledged that it was not.