Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to ensure timely reporting of alleged abuse incidents to the State Survey Agency as required by both facility policy and regulatory guidelines. Specifically, an allegation of staff-to-resident sexual abuse involving a resident with moderate cognitive impairment and multiple psychiatric and medical diagnoses was not reported to the Statewide Incident Management System (SIMS) within the mandated two-hour timeframe, nor was it reported at all. The Director of Nursing (DON) was notified of the allegation and informed the Administrator, who decided not to report the incident, believing it was not necessary. Additionally, an allegation of resident-to-resident physical abuse involving another resident with significant cognitive and physical impairments was also not reported to SIMS. The DON, who was responsible for reporting, did not enter the incident into the system due to lack of administrative approval. The Administrator confirmed awareness of the incident but chose not to initiate a report, stating it was not warranted. These actions resulted in the failure to comply with required abuse reporting protocols for two of four sampled residents.