Failure to Timely Report Allegations of Abuse, Neglect, and Exploitation
Penalty
Summary
The facility failed to ensure timely reporting of allegations of potential exploitation and/or abuse to the State Agency for four residents. According to the facility's policy, all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are to be reported immediately, but not later than two hours after the allegation is made if the events involve abuse or result in serious bodily injury. However, the facility did not adhere to this policy in several instances, as evidenced by record reviews and staff interviews. For one resident with dementia and a history of falls, concerns regarding potential financial exploitation by family members were known to the facility since June, but were not reported to the State Agency or local police until months later, during the surveyors' investigation. The resident was severely cognitively impaired and unable to manage her own finances, with her responsible party refusing to provide information about the resident's assets. Multiple attempts were made by the facility to obtain this information, and involuntary discharge notices were issued due to non-payment, but the potential exploitation was not reported until prompted by surveyors. In another case, a resident with severe cognitive impairment was found with a bruise of unknown origin. The injury was identified and documented, but the incident was not reported to the State Agency until almost 24 hours later, exceeding the required two-hour reporting window. Additionally, a verbal altercation between two severely cognitively impaired residents was not reported to the State Agency until nearly 12 hours after the incident. In all cases, facility leadership confirmed that the incidents were reported late and acknowledged that they should have been reported within the required timeframe.