Failure to Timely Report Allegations of Abuse and Notify Supervisory Staff
Penalty
Summary
The facility failed to timely report allegations of abuse to the state survey agency and did not ensure immediate notification of supervisory staff regarding abuse incidents involving multiple residents. According to facility policy, allegations of resident abuse must be reported to the appropriate state regulatory authority within two hours. However, documentation revealed that an incident involving physical aggression between two residents was reported to the state agency four and a half hours after it occurred, exceeding the required timeframe. The Director of Nursing (DON) confirmed that the report was not submitted within the mandated two-hour window. Additionally, the facility did not ensure that staff immediately reported an allegation of resident-to-resident sexual abuse to the DON or Executive Director. In one case, a resident with severe cognitive impairment touched another resident inappropriately, but the incident was not reported to the DON or state agency until the following day. The DON and Executive Director both acknowledged that the incident should have been reported within two hours, and that the responsible LPN failed to follow the notification process. Another incident involved a resident who sustained bruising and swelling to the hand after allegedly having an inhaler forcibly removed by an LPN. The resident reported the injury to nursing leadership several days after the incident, and the state agency was not notified until hours after the injury was identified. The DON and Executive Director both acknowledged that the incident was not reported in a timely manner, as required by facility policy.