Failure to Timely Report Alleged Abuse to Administrator and State Agency
Penalty
Summary
The facility failed to ensure that a potential allegation of abuse was reported in a timely manner to both the Administrator and the State Survey Agency (SSA) for two of six residents reviewed for abuse. In one case, a resident with a diagnosis of adjustment disorder with anxiety and a BIMS score indicating cognitive intactness was involved in a verbal altercation with an LPN. The resident reported that the LPN shoved medications in his face, leading to a confrontation in which the resident threatened the LPN with a wet floor sign, and the LPN responded by threatening to strike the resident with a water pitcher. The incident was observed by another LPN, who reported it to the on-call manager, but the Administrator was not notified at the time of the incident. The facility's internal investigation confirmed that verbal abuse occurred, but the initial report to the SSA was not submitted until two days after the incident. The Administrator confirmed that she was not informed of the incident when it occurred and did not report it within the required two-hour timeframe. The required initial and 5-day follow-up reports to the SSA were also not submitted within the mandated timeframes. The delay in reporting was due to the incident only being brought to the Administrator's attention after a concern note was left by the LPN two days later.