Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of potential abuse to the State Agency within the required timeframe for one resident. According to the facility's policy, any suspected abuse, neglect, or exploitation must be reported immediately, but not later than two hours after the allegation is made if it involves abuse or results in serious bodily injury. In this case, a resident with a history of bipolar disorder, cognitive impairment following a stroke, osteoarthritis, and generalized anxiety disorder reported to nursing staff that a CNA applied excessive pressure to her left leg during incontinence care, resulting in a large hematoma. Documentation showed that the resident informed a registered nurse about the injury, and the nurse made a late entry in the progress notes regarding the resident's report. Multiple staff members, including a CNA and a certified medication assistant, observed the bruise and were aware of the resident's allegation that staff caused the injury. The CNA involved reported the incident to the facility administrator, and other staff members documented their observations and interactions with the resident regarding the injury. Despite these reports and observations, the facility administrator did not notify the State Survey Agency of the abuse allegation until the administrator was made aware of the situation, which was not within the required two-hour window. The administrator confirmed that the progress note entered by the registered nurse constituted an allegation of abuse and acknowledged that it should have been reported within two hours, but was not.