Failure to Timely Report Alleged Abuse to State Survey Agency
Penalty
Summary
The facility failed to report an allegation of potential abuse to the State Survey Agency within the required two-hour timeframe. According to facility policy, any alleged violations involving abuse must be reported immediately, but no later than two hours after the allegation is made if the event involves abuse or results in serious bodily injury. In this case, a certified nursing assistant (CNA) observed another CNA roughly slam a resident into the wall while turning her in bed. The observing CNA reported the incident to the hall nurse and texted the nurse manager, but did not inform the Administrator until nearly two days later. The Administrator did not report the alleged abuse to the state survey agency or enter it into the Bureau of Facility Standards (BFS) portal as required. The resident involved had multiple diagnoses, including cerebral palsy and chronic obstructive pulmonary disease. During an interview, the Administrator acknowledged that the incident was not reported within the mandated two-hour window. This lapse in timely reporting was identified through policy review, record review, BFS portal review, and staff interviews.