Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to ensure that alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, and not later than 24 hours to other officials, as required by federal and state regulations. In multiple instances, staff did not follow the facility's abuse prevention policy, which mandates prompt reporting of all alleged abuse, neglect, exploitation, or mistreatment. The deficiency was identified through interviews, observations, and record reviews for four residents who were reviewed for abuse. One incident involved a resident with chronic respiratory failure, COPD, morbid obesity, and chronic kidney disease, who was struck by objects during a disruptive event in the dining room. The incident was not reported to the state agency until several days after it occurred, despite the resident's family expressing concern and intent to press charges. Staff interviews confirmed delays in removing residents from the area and in notifying appropriate authorities. The administrator acknowledged that the abuse incident was not reported in a timely manner due to confusion over which agencies to notify. Other cases included a resident with severe cognitive impairment who was allegedly locked in a conference room by staff, with the incident not reported to the administrator or state agency until several days later. Another resident with dementia and Parkinson's disease was reportedly handled roughly by a staff member, but the allegation was not escalated to the administrator or reported to the state agency within the required timeframe. In each case, staff interviews and documentation revealed a lack of immediate reporting, despite facility policy and staff education on the required procedures.