Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner for a resident with severely impaired cognition and multiple diagnoses, including Alzheimer's disease and anxiety disorder. According to the facility's policy, allegations of abuse must be reported to the State Agency within 2 hours. On the date of the incident, a staff member intentionally sprayed the resident with cold water during a shower, an act witnessed by two other CNAs. The resident reacted by grabbing the shower head and banging it against the wall, and verbally expressed discomfort due to the cold water. Both witnesses acknowledged the incident but did not report it immediately, with one stating she was new and the other admitting she did not initially recognize the act as abuse. Interviews with staff revealed that both witnesses were present during the incident and discussed it afterward, but delayed reporting it to facility leadership. The Director of Nursing and Administrator confirmed that the expectation was for immediate reporting of suspected abuse, which did not occur in this case. The facility lacked documentation showing that the allegation was reported to the State Agency within the required 2-hour timeframe following the incident.