Failure to Timely Report Allegation of Abuse to State Agency
Penalty
Summary
The facility failed to ensure that all allegations of abuse and neglect were reported immediately to facility management and to the State Survey Agency within the required two-hour timeframe. An allegation of employee-to-resident abuse involving a resident with dementia and moderate cognitive impairment was not reported in a timely manner. The incident reportedly occurred late at night, but the facility administrator was not notified until several days later, and the state agency was not informed until hours after the administrator became aware. Documentation and interviews revealed that multiple staff members became aware of the resident's allegation that a staff member engaged in inappropriate behavior in the resident's room. The information was discussed among CNAs and reported to the nurse on duty, but there was a delay in escalating the report to the Director of Nursing and the Administrator. The Administrator only became aware of the allegation days after the incident, and the required report to the state agency was not made within the mandated two-hour window after the allegation was known to facility management. The resident involved had recently been admitted, had a diagnosis of dementia, and was dependent on others for activities of daily living. The facility's own policies required immediate reporting of abuse allegations to management and the state agency, but these procedures were not followed. Staff interviews confirmed knowledge of the reporting requirements, yet the delay in reporting resulted in noncompliance with state and facility policies.