Failure to Timely Report Alleged Abuse and Notify Authorities
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than two hours after the allegation was made, as required by regulation. Specifically, an incident occurred in which a male resident with severe intellectual disability, schizoaffective disorder, ADHD, cerebral palsy, and cognitive communication deficit was allegedly grabbed by the shirt near his neck by an LVN during an altercation with his roommate. Two CNAs witnessed the event, with one reporting that the resident made a choking noise and cried after being released. Both CNAs considered the actions to be abuse. Despite witnessing the incident, the CNAs did not immediately report the alleged abuse to the abuse coordinator or other appropriate authorities. One CNA sent a text message to the DON late in the evening, but did not attempt to call or notify anyone else, and was unaware of who the abuse coordinator was. The DON did not see the text until the following morning and only then initiated the reporting and investigation process. The administrator and DON both confirmed that the incident was not reported to the state agency until the next morning, well beyond the required two-hour timeframe. Interviews revealed that staff were unclear about the reporting process, the identity of the abuse coordinator, and the urgency required in reporting suspected abuse. Record reviews and interviews confirmed that the facility's policies required immediate reporting of abuse, but staff failed to follow these protocols. The incident was not reported in a timely manner, and the required notifications to the administrator and state agency were delayed. The deficiency was identified as Immediate Jeopardy due to the failure to report the allegation of abuse within the mandated timeframe and the lack of staff knowledge regarding abuse reporting procedures.