Failure to Timely Report Abuse Allegation to Ombudsman
Penalty
Summary
The facility failed to report an allegation of employee-to-resident abuse to the Ombudsman as required by its abuse policy. A resident with diagnoses including Parkinson's disease, hemiplegia, and hemiparesis, and with intact cognition, reported to a registered nurse that two certified nursing assistants had hit her during hygiene care and repositioning. The incident was documented in the resident's records, and the nurse reported the allegation to the state survey agency and local law enforcement within two hours, but neglected to notify the Ombudsman. The facility's policy and state and federal regulations require that all allegations of abuse be reported to the Ombudsman within two hours by phone and followed by a written report within 24 hours. Interviews with facility staff, including the registered nurse and the director of nursing, confirmed that the Ombudsman was not notified of the abuse allegation as required. The director of nursing, acting as the abuse coordinator, acknowledged that the failure to notify the Ombudsman was a deviation from both facility policy and regulatory requirements. The omission was also confirmed through review of the facility's abuse prohibition and prevention program policy.