Failure to Timely Report Alleged Abuse and Incomplete Investigation Documentation
Penalty
Summary
Facility staff failed to report an allegation of abuse in a timely manner involving one resident who was witnessed hitting another resident in the face. The incident occurred on 12/27/24, but the report to the state agency was not made until 12/30/24, exceeding the facility's policy requirement to report such allegations within two hours if abuse or serious bodily injury is involved. Documentation in the facility's event synopsis and the final report to the state agency confirmed the delay in reporting. The incident resulted in one resident sustaining discoloration to the side of the face, and both the medical doctor and responsible party were updated. Upon review of the facility's investigation file, there was no evidence of a completed investigation, as the only documents present were clinical records for the residents involved. There were no witness statements, staff or resident interviews, or assessments of the residents involved or any other residents. Interviews with administrative staff confirmed awareness of the reporting requirements, but the deficiency was identified due to the lack of timely reporting and insufficient documentation of the investigation process.