Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse to the Department of Inspections, Appeals and Licensing (DIAL) in a timely manner for two residents. In one incident, a resident with quadriplegia and profound intellectual disabilities, who was non-verbal and completely dependent on staff, was found by a CNA being touched on the face by another resident who was masturbating. The CNA immediately intervened, separated the residents, and reported the incident to an LPN, who documented the event and notified the Administrator. Despite this, the Administrator determined the incident did not need to be reported to DIAL at that time, and the event was not reported as required by facility policy and state regulations. In another case, a cognitively intact resident alleged that an LPN withheld medication and used profanities towards him. Multiple staff statements confirmed a verbal altercation involving yelling and cursing between the resident and the LPN, with the LPN reportedly making inappropriate comments about the resident's pain medication. The Administrator was not informed of the incident until several days later, after the resident reported the alleged abuse directly. Facility policy requires that all allegations of abuse, neglect, exploitation, or mistreatment be reported immediately to the Administrator and the State Survey Agency, with specific timeframes for reporting depending on the severity of the incident. Staff interviews and record reviews confirmed that these requirements were not met in both cases, resulting in a failure to report suspected abuse in a timely manner.