Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse or neglect were reported to the administrator and the state agency within 24 hours, as required. Specifically, an incident occurred in which one resident was found holding another resident down on the floor, with the second resident attempting to release himself and calling for help. Staff responded to the incident, and both the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were notified immediately. However, the incident was not reported to the state agency within the required timeframe, as it was not considered abuse by the DON due to the lack of witnesses, inability of the residents to recount the event, and absence of injuries. The residents involved both had severe cognitive impairments and multiple medical diagnoses, including progressive neurological conditions, Alzheimer's disease, seizure disorder, anxiety, depression, and psychotic disorder for one resident, and heart failure, renal failure, diabetes, non-Alzheimer's dementia, anxiety, depression, insomnia, and malnutrition for the other. Both residents had care plans addressing behavioral issues, such as wandering and potential for physical aggression, with interventions in place to manage these risks. Despite these care plans, the incident of physical aggression occurred, and the facility's response did not meet regulatory requirements for timely reporting. Interviews with facility leadership revealed a lack of consensus and understanding regarding what constitutes reportable abuse, particularly in cases without witnesses or visible injuries. The interim administrator and DON provided differing interpretations of the reporting requirements, and the only documentation of the investigation was a brief typed note. The facility's own policy required immediate reporting of suspected abuse or neglect to the administrator and appropriate agencies, but this was not followed in this case.