Failure to Timely Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse, neglect, or theft, and did not submit the results of investigations to the State Survey Agency (SSA) within the required timeframes for multiple residents. In several instances, staff were made aware of allegations of physical and sexual abuse, as well as injuries of unknown origin, but these were not reported to the SSA within two hours as required by facility policy and federal regulations. For example, one resident reported being physically abused by a registered nurse, and although staff notified the Director of Nursing (DON), the allegation was not reported to the SSA. Another resident alleged being pushed by a housekeeper, but the initial report to the SSA was delayed and the follow-up investigation was not submitted within five working days. Additionally, there were failures to report and investigate allegations of sexual abuse and retaliation between residents. One resident reported an incident involving another resident attempting to touch their genitals and subsequent feelings of intimidation and isolation. Staff were informed of these allegations, but the facility did not report them to the SSA as required. In another case, a resident with severely impaired cognition was found with discoloration on their arm, and while an initial report was submitted, the final investigation report was not provided to the SSA. The facility's own policy required immediate reporting of abuse allegations to the administrator and appropriate authorities, defining 'immediately' as within two hours for incidents involving abuse or serious bodily injury. Despite this, multiple incidents were either not reported, not reported timely, or not followed up with the required documentation to the SSA. These failures were identified through observation, interviews, record reviews, and policy reviews, and were determined to have caused, or were likely to cause, serious injury, harm, impairment, or death to residents.
Removal Plan
- Statements were obtained from involved residents #41, #22 and #33 by the Nurse manager.
- Resident #41, Resident #22, and Resident #33 were assessed to ensure no injuries, physical or psychological, were present by the nurse manager.
- RN #20 and Housekeeper #28 have been suspended by Regional Director of Operations.
- The administrator and director of nursing have been suspended by Regional Director of Operations.
- Statements were obtained from the accused employees #20 and #28 by Regional Nurse.
- Social Services has met with involved residents #41, #22 and #33 to address any psychosocial concerns.
- Residents #41 (allegation of physical abuse) and #33 (allegation of sexual abuse) responsible parties were made aware of the allegations by Nurse manager. Education provided for timely abuse reporting based on CMS regulation.
- Medical Directors were made aware of the allegations of physical and sexual abuse.
- Police were notified of the allegations of physical and sexual abuse. Maryland Department of Health was notified of the allegations of physical and sexual abuse.
- Medical Directors were notified of the allegations of physical and sexual abuse for residents #41 and #33.
- Ombudsman was notified of the allegations of physical and verbal abuse.
- Trauma informed evaluations completed for identified residents #41 and #33.