Failure to Timely Report Allegations of Abuse, Neglect, and Misappropriation
Penalty
Summary
Surveyors found that the facility failed to ensure timely reporting of allegations of abuse, neglect, and misappropriation involving seven residents to the State Survey Agency, as required by federal and state law. Multiple grievances were filed by residents or their representatives, each containing allegations of neglect or misappropriation, but none of these were reported to the appropriate authorities within the mandated timeframes. The facility's own policies require immediate or 24-hour reporting of such allegations, depending on the severity, but these procedures were not followed. Specific incidents included residents reporting not being changed for extended periods, having to wait excessive times for call lights to be answered, and being left in soiled conditions overnight. In one case, a resident's representative reported that the resident was not cleaned up after a bowel movement until late in the morning, and another grievance involved a staff member refusing to assist a resident after responding to a call light. Additionally, an allegation of misappropriation was made when a resident was observed giving money to kitchen staff, but this was also not reported to the State Agency. Interviews with facility staff, including the Life Coach and Director of Nursing, revealed a lack of clarity and understanding regarding what constitutes reportable abuse or neglect. Staff admitted to not always knowing when to escalate grievances to administration for reporting. Despite being made aware of the allegations and the facility's policy requirements, no explanations were provided by facility leadership for the failure to report these incidents to the State Survey Agency.