Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported immediately, but not later than two hours after the allegation was made, as required by federal regulations. Specifically, a resident alleged that another resident put drugs in her beer, which led to her experiencing chest pain and being sent to the hospital. Despite the seriousness of the allegation, the facility did not report the incident to Health and Human Services within the required timeframe. The Director of Nursing (DON) and Administrator were both aware of the allegation but chose not to report it, citing the absence of evidence from hospital tests and the belief that the incident did not occur. The events leading to the deficiency involved two residents with complex medical and psychosocial histories. The resident making the allegation had diagnoses including bipolar disorder, anxiety, COPD, and a history of substance use and cognitive impairment. She reported feeling unwell after consuming a drink provided by another resident and subsequently called 911, resulting in police and ambulance involvement. Documentation shows that staff, including nurses and the ADON, were aware of the allegation and the resident's subsequent hospital visit, but the required abuse report was not made to the state agency. Interviews with facility leadership revealed a lack of clarity and consistency in handling the allegation. The DON admitted that the report was not made because hospital tests were negative, while the Administrator believed the incident occurred off-site and therefore did not require reporting. Both leaders demonstrated uncertainty about reporting requirements and failed to document their decision-making process. The facility's policy required reporting all allegations of abuse within the federally mandated timeframe, but this was not followed in this case.