Failure to Timely Report Allegations of Abuse and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to report multiple allegations of abuse, neglect, and resident-to-resident altercations to the State Survey Agency as required by its own policy and federal regulations. In several instances, staff immediately notified the Nursing Home Administrator (NHA) of alleged incidents, including physical and verbal abuse, sexual abuse, and physical threats among residents. Despite these reports, the NHA did not submit the required notifications to the State Survey Agency within the mandated timeframes, which are two hours for abuse or serious bodily injury and 24 hours for other incidents. In some cases, law enforcement was also not notified as required. Specific incidents included staff witnessing one resident repeatedly hitting another with a pillow, a resident making threatening statements, and a resident physically assaulting another, resulting in a skin tear. There were also allegations of sexual abuse, where staff observed inappropriate touching or situations suggestive of sexual misconduct. In each case, the NHA either determined that the incident did not occur as reported or relied on informal, unsigned staff statements, and therefore did not report the allegations to the State Survey Agency. The facility maintained informal 'soft files' with typed but unsigned staff statements for some incidents, while in other cases, no documentation was available. Additionally, there was an instance where the facility conducted an investigation into a resident-to-resident altercation but submitted the completed investigation to the State Agency late due to the NHA's personal emergency. The report also notes that some staff failed to immediately notify the NHA of an incident, and documentation in the electronic medical record reflected staff perceptions rather than objective facts. The NHA acknowledged responsibility for submitting facility-reported incidents but stated that, based on witness statements, the incidents did not warrant reporting.