Failure to Timely Report Resident Abuse Allegation to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse made by a resident to the State Agency, the ombudsman, and local law enforcement as required. The incident involved a resident with a history of cognitive impairment, schizophrenia, and depression, who stated to an LVN that he was hit by staff when being assisted. The LVN assessed the resident for injuries and found none, and subsequently did not report the allegation to the Administrator or the required authorities, as she did not believe the claim was true due to the absence of physical evidence and her own observations. The facility's policy and recent in-service training required all staff to report any abuse allegations immediately, regardless of their personal belief in the validity of the claim or the presence of physical evidence. The LVN had received this training but failed to follow the protocol, resulting in the Administrator and DON not being informed of the allegation. The DON and Administrator both confirmed during interviews that the LVN was responsible for reporting the allegation so that an investigation could be initiated. The failure to report the abuse allegation led to a delay in notification to the appropriate authorities and a delay in the initiation of an onsite inspection. The facility's own performance improvement plan identified communication breakdowns as a root cause for such incidents, emphasizing the need for prompt reporting of all abuse allegations to ensure proper investigation and resident safety.