Failure to Timely Report Suspected Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse prevention policy by not reporting a suspected abuse incident to the State Survey Agency within the required two-hour timeframe after the allegation was made. A resident with moderate cognitive impairment and multiple medical conditions, including acute kidney failure and chronic heart failure, was reportedly handled roughly by a male CNA during a night shift. The resident's responsible party informed an LVN of the incident, but the LVN did not notify the RN Supervisor or the abuse coordinator as required by facility policy and instead advised the responsible party to follow up with management on the next business day. Multiple staff interviews confirmed that the allegation of rough handling was communicated to the LVN on the day it was reported, but the LVN did not escalate the report immediately. Other staff, including another CNA and RN, stated that such allegations should be reported to the abuse coordinator and investigated without delay, regardless of the time or day. The facility's policy clearly states that all allegations of abuse, neglect, or mistreatment must be reported immediately, but not later than two hours after the allegation is made, to the appropriate authorities. The delay in reporting resulted in the abuse allegation not being communicated to the State Survey Agency, ombudsman, and law enforcement within the required timeframe. The administrator only became aware of the incident the following day and subsequently reported it approximately six hours after being informed. This failure to follow established reporting procedures placed residents at risk for potential continued abuse and delayed investigation.