Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to ensure that staff reported allegations of abuse within the required two-hour timeframe, as mandated by both facility policy and regulatory requirements. In the case of one resident with a history of Parkinson's disease, bipolar disorder, and dementia, the resident alleged that a staff member hit them with a metal rod. The incident occurred in the early morning hours, and although emergency services and police responded promptly, the Director of Nursing (DON) did not notify the Administrator until several hours later, and the initial report to the state survey agency was not submitted until the afternoon. Multiple staff members who were present or aware of the allegation did not report it immediately, with some assuming that the presence of a supervisor or the lack of observed abuse negated the need for reporting. Another resident, with diagnoses including a displaced fracture, schizophrenia, and psychosis, made several statements to staff and a physician about being abused. These statements were documented in progress notes but were not reported to the appropriate authorities or the facility's abuse coordinator in a timely manner. The Assistant Director of Nursing (ADON) only became aware of a new allegation after being notified by a hospital liaison, and subsequently reported it to the Administrator and state survey agency, but this report was also submitted late. Interviews with staff revealed a lack of awareness or recall regarding the need to report such allegations, and the DON and Administrator acknowledged that the reports were not made within the required timeframe. The deficiency affected two residents who were reviewed for abuse or neglect. Both cases demonstrated failures in communication and adherence to policy regarding the timely reporting of abuse allegations. Documentation in the residents' records indicated that staff either did not recognize the need to report or assumed others would handle the reporting, resulting in significant delays in notifying both facility administration and the state survey agency as required.