Failure to Timely Report Abuse Allegations and AMA Discharges
Penalty
Summary
The facility failed to ensure that allegations of abuse were reported to law enforcement within the required two-hour timeframe. Specifically, a resident with moderate cognitive impairment and significant dependence on staff for activities of daily living made an allegation of sexual abuse by a staff member. The incident was not reported to law enforcement within two hours as required by facility policy, and staff could not provide a reason for the delay, despite acknowledging the requirement. Additionally, the facility did not properly log or report residents who left against medical advice (AMA) to Adult Protective Services (APS) or the State Agency. Three residents with varying medical conditions, including congestive heart failure, cirrhosis, hip fracture, anxiety disorder, and chronic obstructive pulmonary disease, left the facility AMA. In these cases, there was no documentation of the incidents in the facility's log, nor evidence that APS was contacted, even when residents' whereabouts were unknown or their safety was potentially at risk. Staff interviews confirmed that these discharges should have been reported to APS, but this was not done.