Failure to Timely Report and Accurately Document Suspected Abuse Incidents
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to ensure the timely reporting of suspected abuse, neglect, or theft, as required by section 1150B of the Act. In multiple incidents involving three residents, staff did not accurately or promptly report resident-to-resident physical altercations to the appropriate authorities. Documentation submitted to the State Agency did not fully represent the extent of the events as recorded in witness statements and the electronic medical record (EMR). For example, an incident where one resident struck another in the face was not reported to the Administrator until approximately seven hours after it occurred, and the initial report did not reflect the severity of the injury, which was later determined to be a fractured jaw. Further review revealed that staff, including a nurse who witnessed the incidents, did not consistently report all observed altercations. The nurse described witnessing additional aggressive interactions between residents, including physical assaults, but admitted to not reporting some of these events. The nurse also indicated a lack of training regarding the facility's abuse reporting protocols and expectations. There was no evidence that this nurse had received any abuse prevention or reporting education from the facility, despite the facility's claim of recent staff education efforts. Interviews with the Administrator and DON confirmed gaps in understanding and execution of reporting requirements. The Administrator delayed reporting an incident based on an initial assessment that there was no injury, only reporting after learning of a serious injury. The facility's own policy required immediate reporting of all allegations or suspicions of abuse to the Administrator and state agencies, but this was not followed. Additionally, the facility could not provide evidence that all staff, including agency nurses, had received the required training on abuse reporting procedures.