Failure to Timely Report Alleged Abuse and Notify Authorities
Penalty
Summary
The facility failed to timely report an allegation of abuse involving a resident who was found in a wheelchair with two dining room chairs placed behind it, preventing backward movement. The Maintenance Supervisor discovered the situation early in the morning and immediately removed the chairs, then notified the Dietary Manager. The concern was brought up at a quality assurance meeting later that morning and reported to the Assistant Director of Nursing (ADON), who acknowledged awareness but did not escalate the issue. The Administrator was not present at the meeting and was not informed until the following day, after which the incident was reported to the Department of Inspection, Appeals and Licensing (DIAL) more than a day after the initial observation. The facility also failed to notify law enforcement of the abuse allegation, as required by policy. Staff interviews revealed that the incident was not recognized or reported as abuse in a timely manner, and the facility's own policy required immediate reporting to state authorities and law enforcement. The delay in reporting and lack of immediate action by responsible staff contributed to the deficiency, as the incident was not addressed according to regulatory and facility policy requirements.