Failure to Timely Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or misappropriation of property to the State Agency for four residents, as required by regulation and facility policy. In one case, a resident with a history of alcohol dependence and anxiety disorder was alleged by a family member to have had her debit card taken and used by a staff member. The resident initially confirmed the allegation to the Nursing Home Administrator (NHA) and Director of Nursing (DON), resulting in the suspension of the accused staff member. However, after the family member left, the resident retracted her statement, claiming she felt pressured to make the accusation. Despite the retraction, both the DON and NHA acknowledged that the initial allegation constituted a reportable event, but it was not reported to the State Agency. Additional incidents involved residents with severe cognitive impairment. Two separate altercations occurred between residents, resulting in physical contact and complaints of pain. Incident reports documented these events, including one where a resident's arm was grabbed and another where residents swung at each other, making contact. The NHA, who was responsible for abuse investigations, was not initially notified of these incidents. Upon later review of the incident reports, the NHA agreed that these events met the criteria for abuse allegations and should have been reported and investigated, but no such actions were taken at the time. Facility policy clearly defined abuse to include staff-to-resident and resident-to-resident altercations, and required immediate investigation and reporting of all allegations to the appropriate authorities. Despite this, the NHA signed off on incident reports without ensuring that the required notifications and investigations were completed. The failure to report these incidents as required resulted in a deficiency related to the timely reporting and investigation of suspected abuse, neglect, or misappropriation.