Failure to Timely Report Alleged Abuse and Neglect Incidents
Penalty
Summary
The facility failed to report multiple incidents of alleged abuse, neglect, or theft involving residents, as required by state law, within the mandated timeframe of no later than two hours after the allegation was made. The deficiency was identified through interviews and record reviews, which revealed that for 19 residents reviewed for abuse or neglect, none of the incidents were reported to the proper authorities, including the State Survey Agency. The events included physical altercations, inappropriate sexual contact, verbal aggression, and actions resulting in serious bodily injury, such as a resident being pushed to the floor and sustaining a broken hip. Specific incidents that were not reported included a resident groping another resident, slapping, punching, and attempting to stab with a fork, as well as residents engaging in mutual physical altercations. In several cases, the residents involved had documented histories of severe cognitive impairment, dementia, or psychiatric disorders, and their care plans often noted a risk for aggressive or inappropriate behaviors. Despite these known risks and the occurrence of actual incidents, the facility did not fulfill its obligation to report these events to the appropriate authorities in a timely manner. The deficiency was further substantiated by a cross-reference of the facility's incident log with the state reporting system, which confirmed that the incidents were not reported. Progress notes and care plans detailed the residents' medical and behavioral histories, the nature of the incidents, and the immediate actions taken by staff, such as notifying the DON or obtaining psychiatric consultations. However, there was no evidence that the required external reporting was completed for any of the incidents reviewed.