Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was reported immediately to facility management and within two hours to the State Survey Agency, as required by both facility policy and regulation. The incident involved a resident with severe cognitive impairment and multiple diagnoses, including dementia and Alzheimer's disease, who required total assistance with activities of daily living. On the evening of the incident, a Certified Nurse Aide (CNA) was observed by another CNA placing a hand over the resident's mouth and telling the resident to "shut the fuck up" while the resident was crying. The witnessing CNA did not report the incident immediately but instead informed another CNA the following day, who then reported it to the Director of Nursing (DON) and the Administrator. Documentation and interviews confirmed that the facility did not report the allegation to the Department of Health and Senior Services (DHSS) until the day after the incident, exceeding the required two-hour reporting window for abuse allegations. Staff interviews revealed that employees were aware of the policy to report abuse immediately and to notify the state within two hours, but the initial witness failed to follow this protocol. There was no documentation of immediate reporting to DHSS in the resident's records, and the delay in reporting constituted a failure to comply with both facility policy and regulatory requirements.