Failure to Timely Report Allegations of Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to follow its abuse prevention policy by not notifying the State Survey Agency within the required two-hour timeframe after becoming aware of allegations of abuse, neglect, or injury of unknown origin for six residents. In multiple instances, staff became aware of allegations or observations of potential abuse, such as bruising, rough care, inappropriate touching, and medication errors, but the initial reports to the State Survey Agency were delayed, ranging from over two to more than forty-eight hours after the incidents were known. Documentation and interviews confirmed that staff recognized these events as reportable and initiated internal investigations, but did not meet the mandated reporting timeframe. Specific cases included family members and staff reporting bruising, allegations of rough handling by CNAs, inappropriate contact by a staff member, and a medication error. In each case, the facility's own records and staff interviews confirmed the time the allegation was known and the time the report was sent, showing delays beyond the policy requirement. The facility's abuse prevention policy, revised in October 2022, requires immediate reporting, but not more than two hours after the allegation is known, which was not followed in these cases.