Failure to Timely Report Allegations of Abuse to State Agency
Penalty
Summary
The facility failed to report allegations of abuse to the State Survey Agency, the Office of Health Care Quality (OHCQ), within the required 24-hour timeframe for two residents. In the first instance, a resident with diagnoses including shortness of breath, dementia, and osteoarthritis of the right shoulder sustained two large skin tears on both forearms while being assisted out of a chair by a Hospitality Aide who was not qualified to provide resident care. The incident was documented in a complaint and confirmed by the aide, but a review of the clinical record and investigative notes revealed that the incident was not reported to OHCQ as required. In the second instance, another resident reported an allegation of abuse to a Unit Manager, but the Unit Manager did not inform the administration. The allegation was not reported to OHCQ until three days later, after the resident brought the matter to the attention of the DON and Administrator. These failures to report suspected abuse in a timely manner were confirmed through staff interviews and review of facility documentation.