Failure to Timely Report Alleged Abuse and Investigation Results
Penalty
Summary
The facility failed to ensure timely reporting of alleged violations involving abuse, neglect, or misappropriation of resident property, as well as timely submission of investigation results to the appropriate authorities. Specifically, the facility did not report allegations of abuse or neglect within the required two-hour or 24-hour timeframes, nor did it submit the results of investigations within five working days as mandated by both facility policy and state regulations. This deficiency was identified in three out of seven residents reviewed during the survey. One resident with schizophrenia and anxiety reported being punched in the face by an LPN and was observed with a small cut on the upper lip. The incident was reported to the state several hours after the allegation, and the results of the investigation were not submitted within the required five-day period. Another resident with chronic pain and anxiety complained of back pain and alleged that an LPN pulled their arm backward while they were sleeping. The incident was reported to the state later that day, but again, the investigation summary was not submitted within five days. In both cases, the facility's investigations concluded that no abuse occurred, but the required reporting timelines were not met. A third resident with Alzheimer's disease and severe cognitive impairment was found with a head wound and transferred to the hospital, where it was later determined that the injury was more severe than initially assessed. The incident was not reported to the state until several days after the resident's return from the hospital, and the delay was attributed to the facility's late realization of the injury's severity. Interviews with the DON and Administrator confirmed awareness of the reporting requirements but acknowledged failures to report both the initial allegations and the investigation results within the mandated timeframes.