Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources, were reported immediately to the facility administrator and to the State Survey Agency as required. Specifically, a resident with moderate cognitive impairment and a recent history of behavioral issues, including hallucinations, delusions, and aggression, reported an allegation of abuse that occurred during a recent hospital stay. The resident alleged that while at the hospital, she was taken to a back room and physically abused by a man. Upon her return to the facility, nursing staff documented her report and noted some bruising, but no injuries to the perineal area as described in her allegation. Despite the facility's policy and state requirements mandating immediate reporting of such allegations, the administrator did not report the incident to the State Survey Agency, reasoning that the alleged abuse occurred outside the facility. The administrator did inform the ADO, but no further action was taken at that time. The incident was not reported to the State office until several days later, after the ADO and Regional Compliance nurse discovered the allegation during a chart audit. The delay in reporting was attributed to miscommunication and lack of follow-up between the administrator and the ADO, as well as the absence of a DON at the time. Facility policy and state guidelines require that all allegations of abuse, regardless of where they occur, be reported promptly to the appropriate authorities. The failure to report the resident's allegation in a timely manner was confirmed through interviews and record reviews, and it was noted that no self-reported incidents regarding the abuse allegation were found in the state's reporting portal for the resident in question.