Failure to Timely Report and Investigate Alleged Abuse Incidents
Penalty
Summary
The facility failed to report allegations of abuse within the required two-hour timeframe and did not submit timely investigation results to the appropriate governing agencies for several residents. Specifically, incidents involving inappropriate interactions and physical contact between residents were identified, and while initial incident reports were sometimes submitted on time, the final investigations were delayed. The facility's own policy requires prompt reporting and submission of investigation findings, but reviews of incident report forms and external communications showed that final investigations were submitted days or weeks after the incidents occurred. Interviews with the Administrator confirmed awareness of the delays, attributing them to the need for additional review by leadership before submission and a lack of timely follow-up. The residents involved had varying degrees of cognitive impairment, including diagnoses such as paranoid schizophrenia, dementia, and cognitive communication deficits. The delays in reporting and investigation submission were acknowledged by facility leadership, but no corrective actions or follow-up measures were described in the report.