Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that alleged violations involving abuse were reported immediately, but not later than two hours after the allegation was made, for two of six sampled residents. Facility policy requires that any partner with direct or indirect knowledge of an event that might constitute abuse must report the event immediately, and not later than two hours after forming the suspicion, in accordance with federal and state law. Despite this, the facility did not report an incident involving two residents within the required timeframe. One resident, with diagnoses including dementia, delirium, and severe visual impairment, required substantial assistance with daily activities and had poor memory. Another resident, with diabetes, dementia, traumatic brain injury, and schizoaffective disorder, had moderate cognitive impairment and exhibited physical behaviors toward others. An incident occurred in which the second resident was found on top of the first resident in bed, partially unclothed and refusing to get off, requiring multiple staff members to intervene. The first resident was assessed and found to have no injuries, while the second resident was confused and required redirection. Staff interviews and written statements confirmed that the incident was witnessed and reported internally, but the required report to state authorities was not made within the mandated two-hour window. The Administrator acknowledged that the incident was not reported to the state agency and was not discussed in QAPI meetings, despite facility policy and regulatory requirements. The Director of Social Services also confirmed that such incidents should be reported within two hours and that a follow-up investigation is due on the fifth day.