Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources, were reported immediately to the administrator and to the state agency as required by facility policy. Specifically, an incident involving a female resident with severe cognitive impairment and multiple medical conditions was not reported within the required two-hour timeframe. The resident, who was dependent on staff for most activities of daily living and had a history of falls and behavioral disturbances, was involved in an incident where a staff member assisted her back into her wheelchair after she attempted to stand and walk unassisted. A housekeeper witnessed the staff member placing his hands on the resident's shoulders and chest to guide her back into her seat but did not perceive the action as forceful or harmful. However, the housekeeper did not report the incident immediately due to personal reasons and only informed her supervisor the following day. Other staff interviews indicated that the resident required frequent redirection and that the staff member involved was generally regarded as patient and kind. There was no immediate evidence of injury or distress observed in the resident following the incident. Despite facility policy requiring immediate reporting of abuse allegations, the delay in reporting the incident to the administrator and state agency constituted a deficiency. The facility's own policy mandated that such allegations be reported within two hours if abuse or serious bodily injury was involved, but this protocol was not followed in this case.