Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to implement its policies and procedures for the timely reporting of alleged physical abuse in accordance with federal and state requirements. In two separate cases, allegations of abuse involving two residents were not reported to the State Agency or local law enforcement as required. In the first case, local law enforcement notified the facility of an abuse allegation concerning a resident with cognitive impairment and psychiatric diagnoses, but the facility did not submit a Facility Reported Incident (FRI) to the State Agency. The Director of Nursing (DON) stated that due to previous unfounded reports from the resident and his sister, the facility did not believe the allegation warranted reporting or investigation. In the second case, a resident with psychiatric and cognitive diagnoses was subjected to physical restraint and threats by staff during medication administration, as witnessed by a CNA. The CNA reported the incidents to a nurse manager, who acknowledged the behavior as abuse but did not immediately escalate the report to the DON. When the DON was eventually notified, an internal investigation was conducted, and the staff member involved was terminated. However, the facility did not report the allegation to the State Agency or local law enforcement, and the DON stated the decision was made not to report because the notification was delayed and they anticipated being cited for late reporting.