Failure to Timely Report and Document Abuse Allegations to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse incidents to the State Agency as required by its Abuse Prevention Program policy. Specifically, an incident involving a physical altercation between two residents resulted in one resident sustaining a small tear on the left arm. The incident occurred at 12:10 p.m., but the initial state reportable incident form was not submitted until 3:36 p.m., exceeding the two-hour reporting requirement. Additionally, there was no documentation that a final report was received by the State Agency within five business days for this incident. Interviews with staff and the administrator revealed inconsistencies regarding the time of notification and submission of reports, and the administrator acknowledged the report was not submitted in a timely manner if the incident occurred at the documented time. Further review identified another incident involving two residents in the dining room, which was reported initially, but the final incident report was not successfully transmitted to the State Agency. The administrator provided a fax transmission log indicating an unsuccessful attempt to send the final report, as denoted by a code indicating failed communication. The State Agency's database did not show receipt of the final report for this incident. These failures affected three residents and demonstrated noncompliance with both the facility's policy and state requirements for timely reporting and documentation of abuse allegations and investigation results.