Failure to Timely Report Allegation of Abuse Due to Staff Judgment on Resident Credibility
Penalty
Summary
The facility failed to ensure that all allegations of abuse and injuries of unknown origin were reported to the State Survey Agency (SSA) within the required two-hour timeframe. Specifically, a resident with severe cognitive impairment and a history of Lesch Nyhan Syndrome, which includes symptoms of uncontrollable self-injury and behavioral issues, reported to staff that a Certified Nursing Assistant (CNA) had been hitting him at night. Although the facility's policy required immediate reporting of such allegations, the initial report to the Office of Inspector General (OIG) was not submitted until two days after the allegation was made. Interviews with facility staff revealed that while staff were trained to report allegations of abuse to leadership immediately, there was confusion and inconsistency among leadership regarding the necessity and timing of reporting, especially when the resident was known to make frequent and sometimes unsubstantiated claims. The QAPI Manager initiated an internal investigation but did not initially plan to report the allegation due to the resident's history of making false accusations. The decision to report was only made after consultation with the Chief Quality and Compliance Officer, who emphasized the importance of reporting regardless of the resident's diagnosis. Further interviews with the DON and Administrator indicated a reliance on the QAPI Manager to determine reportability and a lack of clarity about the required reporting timeframes. The Administrator stated that if a resident was not considered a reliable reporter and there was no corroborating evidence, the incident might not be reported. Ultimately, the delay in reporting the allegation was attributed to the staff's judgment about the credibility of the resident's report, rather than adherence to the facility's policy and federal requirements.