Failure to Timely Report Abuse, Neglect, or Injury Events
Penalty
Summary
The facility failed to submit timely reports to the State Survey Agency for multiple reportable events involving suspected abuse, neglect, or injury. In five separate cases, the facility did not meet the required two-hour reporting window for incidents involving serious bodily injury or suspicion of abuse. These included unwitnessed falls resulting in injuries such as a vertebral fracture, and an incident where a resident was held down by staff during medication administration, which led to the termination of two staff members for abuse. In each case, the initial or final reports were submitted late, sometimes by more than a day, despite internal notifications and initiation of investigations occurring promptly after the incidents. Interviews with staff revealed a lack of clarity regarding responsibility and procedures for timely reporting. Staff members acknowledged that reports should be filed as soon as possible, especially in cases of serious injury or abuse, but were unable to explain the delays. In some instances, the responsible staff member was not present in the facility at the time of the incident, and reporting was delayed until their return. The facility's investigation processes were noted to be in need of improvement, as evidenced by the repeated late submissions of required reports to the State Survey Agency.