Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner to the State Agency (SA) as required by policy. An incident occurred in which one resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, reported that another resident pulled her hair, struck her in the back of the head, and pushed her wheelchair while outside in the smoking area. The incident was reported by the affected resident to nursing staff immediately after it happened, and the nursing assistant informed both the assistant director of nursing and the charge nurse. The residents involved were placed on 15-minute checks following the report. Despite the immediate internal notification, the facility did not submit the Facility Reported Incident (FRI) to the SA until approximately 25.5 hours after the event, exceeding the required reporting timeframe of no later than 2 hours for allegations involving abuse. The administrator confirmed that the FRI was submitted late, as she was not aware of the full details of the incident until the following day. Additionally, law enforcement was contacted by the resident's family member, and a welfare check was conducted prior to the FRI being submitted to the SA. Facility policy required immediate reporting of all alleged violations to the administrator, state agency, and other authorities within specified timeframes, which was not followed in this case.