Failure to Timely Submit Abuse Investigation Documentation
Penalty
Summary
The facility failed to timely submit documentation of completed investigations to the State Agency regarding alleged resident-to-resident sexual and physical abuse incidents. In the first incident, one resident with severe cognitive impairment was kissed on the mouth by another resident with moderate cognitive impairment. The event was witnessed, and the facility self-reported the incident to the State Agency. However, the five-day completed investigation was not submitted within the required timeframe, as the Nursing Home Administrator was out of town and the DON, who was the backup Abuse Coordinator, was unable to access the reporting system. There was no documentation provided to show communication with the State Agency about this access issue. In the second incident, a maintenance staff member observed a resident with moderate cognitive impairment hitting another resident with severe cognitive impairment with a banana. The incident was reported to the charge nurse, and the involved residents were separated. The five-day completed investigation for this incident was also submitted late due to an oversight by the Nursing Home Administrator. Facility policy and federal regulations require that the results of all investigations be reported to the State Agency within five working days, but this was not done in either case.