Failure to Timely Report Allegation of Abuse/Neglect
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported within the required two-hour timeframe, as outlined in its own policy and regulatory requirements. A resident with a history of anemia, deep vein thrombosis, and other medical conditions alleged that a physical therapist's actions led to hospitalization due to a blood clot. The resident voiced these concerns to therapy staff on multiple occasions, including to an occupational therapist and a physical therapist, and later filed a grievance with the Social Services Director. Despite these reports, there was no documented evidence that the allegations were immediately reported to the Administrator or to the state survey agency as required. The facility's policy mandates that any suspicion of abuse, neglect, or exploitation must be reported immediately, defined as within two hours for allegations involving abuse or serious bodily injury. However, the documentation shows that the initial report to the state survey agency was not made until well after the resident's allegations were first communicated to staff. Specifically, the facility submitted the report to the state agency a day after the resident filed a formal grievance, and several days after the initial concerns were raised with therapy staff. Interviews with staff revealed a lack of clarity and timely action regarding the reporting process. Therapy staff and the Director of Rehabilitation were aware of the resident's allegations but did not escalate the matter to the Administrator or report it to the state agency in accordance with policy. The Administrator only became aware of the situation during a morning meeting after the grievance was filed, at which point the report was made to the appropriate authorities. This delay in reporting constitutes a failure to follow established procedures for timely reporting of suspected abuse or neglect.