Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than two hours after the allegation was made, as required by regulation and facility policy. Specifically, a male resident with multiple medical conditions, including atrial fibrillation, cardiomyopathy, muscle weakness, and incontinence, reported to a physical therapy assistant (PTA) that he felt abused after being left on a bedpan for an extended period. The resident stated that he was left on the bedpan for approximately 90 minutes and described this as abuse. The PTA documented the grievance and immediately notified the management team and the Administrator. Upon receiving the report, the Director of Nursing (DON) and the Administrator promptly interviewed the resident, who then denied being abused and attributed his frustration to a loss of independence and anxiety about an upcoming discharge. Despite the resident's denial during the interview, the initial allegation of abuse was not reported to the State Survey Agency within the required two-hour window. The Administrator acknowledged that the facility's policy mandates reporting all alleged abuse to the state agency within two hours, regardless of subsequent resident statements. The facility's failure to report the initial allegation of abuse within the mandated timeframe constituted a deficiency. The report and interviews confirmed that the staff were aware of the reporting requirements, and the facility's policy was clear on the need for immediate reporting of all alleged violations involving abuse, neglect, or mistreatment, but the required notification to the state agency did not occur as stipulated.