Failure to Timely Report Alleged Abuse, Neglect, and Sexual Incidents
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or theft were reported immediately to the abuse coordinator and, when required, to the State Agency within the mandated timeframes. Multiple incidents involving resident-to-resident physical and sexual aggression, as well as verbal abuse, were not reported as required. In several cases, staff did not notify the abuse coordinator immediately after witnessing or being informed of abuse allegations, and several incidents were not reported to the State Agency within the required two-hour window for abuse or bodily injury, or within 24 hours for neglect. These failures were identified for seven out of ten residents reviewed for abuse. Specific events included a resident throwing coffee and threatening another, resulting in a physical altercation; a resident verbally abusing another, with threats of physical harm; and multiple instances of physical aggression, such as a resident hitting another with silverware and punching another resident in the chest. There were also incidents of sexual abuse, including a resident placing a hand down another resident's pants and a resident rubbing his private area against another resident. In each of these cases, documentation showed that the incidents were either not reported to the abuse coordinator or not reported to the State Agency within the required timeframe. Additionally, an incident of neglect involving a resident's unwitnessed fall with injuries was not reported to the State Agency within 24 hours. The residents involved had significant cognitive impairments, including diagnoses of Alzheimer's disease, dementia, major depressive disorder, and schizophrenia. Many required supervision or assistance for daily activities and had documented histories of behavioral symptoms such as aggression, inattention, and disorganized thinking. Despite these known risks, the facility did not update care plans to reflect new or ongoing aggressive or sexual behaviors following these incidents, nor did staff consistently follow established procedures for reporting abuse, neglect, or theft as required by regulation.