Failure to Timely Report Alleged Abuse and Neglect to State Agency
Penalty
Summary
The facility failed to immediately report allegations of physical and verbal abuse to the State Agency (SA) within the required two-hour window for three residents after family members or the residents themselves reported the alleged abuse. In one case, a resident with dementia and impaired mobility, who required staff assistance for repositioning, and his family member reported that a nursing assistant used inappropriate language and physically handled the resident in a rough manner. The incident was documented by the social worker, and both the administrator and DON were notified, but the required report to the SA was not filed in a timely manner. The resident later expressed reluctance to return to the facility due to the abuse. Another incident involved a resident with moderate cognitive impairment and limited mobility, who was dependent on staff for toileting and transfers. The resident's family member overheard a nursing assistant making punitive statements and denying the resident timely toileting assistance, resulting in the resident being left in a wet brief and nightgown in a public area. The incident was reported to facility leadership, but the SA was not notified within the mandated timeframe. Interviews with staff confirmed that the actions and communication by the nursing assistant could be considered abusive and should have been reported immediately. A third case involved a resident with moderate cognitive impairment who reported being struck on the legs by a nursing assistant when being awakened for dinner. The incident was reported to the SA, but not within the required two-hour window. Facility policy required immediate reporting and suspension of the alleged perpetrator pending investigation, but in these cases, the facility either delayed reporting or did not report at all, and did not consistently suspend the staff involved. Interviews with facility staff and administrators revealed uncertainty and inconsistency in the reporting process, with some incidents being classified as customer service issues rather than abuse, leading to failures in timely reporting as required by regulation.