Failure to Timely Report Alleged Abuse to State Agency and Administrator
Penalty
Summary
The facility failed to ensure that all allegations of abuse were reported to the State Survey agency and the facility administrator immediately, but not later than two hours after the allegation was made, as required. Specifically, a male resident with a history of cerebral infarction, heart failure, and bipolar disorder, who was cognitively intact and required catheter and incontinent care, alleged that an LVN touched him inappropriately during catheter care. The incident occurred on 03/08/25, but the LVN did not immediately report the allegation to the administrator. Instead, the administrator became aware of the incident two days later, on 03/10/25, after finding a note left by the LVN. An assessment and investigation were initiated only after the administrator learned of the incident, and the report to the State Survey agency was also delayed until 03/10/25. The facility's own policy required immediate reporting and investigation of all abuse allegations, but this protocol was not followed in this case. The delay in reporting was confirmed through interviews, record reviews, and a review of the state database, which showed discrepancies in the reporting timeline.