Failure to Timely Report Alleged Abuse and Misappropriation
Penalty
Summary
The facility failed to ensure timely and complete reporting of alleged abuse and misappropriation involving two residents. In the first case, a resident with severe cognitive impairment and multiple medical conditions, including dementia and a recent fall with fracture, was reported by their Activated Power of Attorney (APOA) to have a missing wallet. The Director of Nursing (DON) was notified, and an initial report was submitted to the State Agency on the same day. The facility initiated an investigation and contacted local law enforcement. However, the required 5-day follow-up report to the State Agency was not submitted. The Nursing Home Administrator (NHA) acknowledged the omission, citing issues with email account changes and inability to locate confirmation of the 5-day report submission. In the second case, a cognitively intact resident reported to a surveyor that a Certified Nursing Assistant (CNA) had yelled at and scared them several weeks prior. The resident had informed another CNA, who stated they would file a complaint but did not do so, nor did they inform facility management. The incident was not documented in the facility's incident or grievance logs for the relevant period. When interviewed, the CNA who received the complaint did not consider the situation abusive and did not escalate the report. Facility management, including the Assistant Director of Nursing (ADON) and Social Worker (SW), were unaware of the incident until informed by the surveyor. A grievance was only filed after the surveyor's inquiry, and the alleged perpetrator was no longer employed at the facility. The facility's own policy requires immediate or timely reporting of all allegations of abuse, neglect, or misappropriation to the State Agency and other authorities, as well as submission of a follow-up investigation report within five working days. In both cases, the facility failed to adhere to these requirements: the 5-day follow-up report was not submitted for the missing wallet, and the verbal abuse allegation was not reported to the State Agency at all. These failures were confirmed through interviews and record reviews conducted by the surveyor.