Failure to Timely Report Alleged Abuse Following Resident Fall
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin, were reported to the State Survey Agency within the required 24-hour timeframe. Specifically, a male resident with schizoaffective disorder, major depressive disorder, and dementia, who was at risk for falls, experienced an unwitnessed fall from his bed. The incident was documented in the facility's records, and the RN notified the DON approximately 30 minutes after the fall. However, the event was not reported to the State Survey Agency as required by facility policy and state regulations. Interviews revealed that the DON believed allegations of abuse should be reported within two hours, while the Administrator did not report the fall because there were no injuries observed at the time. Upon review of the abuse guidelines, the Administrator acknowledged the reporting requirement but had not complied. A review of the Texas Unified Licensure Information Portal confirmed that no self-reported incidents regarding the alleged abuse were submitted for the resident on the date of the fall, indicating a failure to follow established reporting procedures.