Failure to Timely Report Allegations of Abuse, Neglect, and Misappropriation
Penalty
Summary
The facility failed to ensure that all allegations of abuse, neglect, exploitation, or misappropriation of resident property were reported immediately, as required by federal and state regulations. Specifically, two incidents involving two residents were not reported to the administrator and appropriate authorities within the mandated timeframes. The first incident involved a male resident who went out on leave during Thanksgiving and returned with missing narcotic medication cards for Tramadol and Tylenol #3. The agency nurse who signed him out did not follow the required procedure of counting and documenting the medications with the resident, nor did she provide the necessary narcotic sheets. Upon the resident's return, staff discovered the narcotic sheets were missing, and there was uncertainty about the quantity of narcotics the resident should have had. Although the incident was reported to the DON, it was not reported as a possible misappropriation or drug diversion to the administrator or state authorities as required. The second incident involved a female resident who reported feeling neglected during her first week of admission. She stated that her colostomy bag broke and she was unable to get assistance despite calling for help, and she believed her call light was intentionally misplaced. The resident reported this to the social worker (SW), who then informed the DON but failed to report the allegation to the administrator, who was also the abuse and neglect prevention coordinator. The DON did not recall being informed about the incident, and the administrator confirmed that the incident should have been reported immediately. The facility's own policies and staff training materials required immediate reporting of such allegations, but these procedures were not followed in either case. Record reviews confirmed that neither incident had been reported in the state's TULIP system, and interviews with staff revealed gaps in following established protocols for reporting and investigating allegations of abuse, neglect, or misappropriation. Both residents had significant medical needs, including pain management with controlled substances and complex wound and ostomy care, which heightened the importance of timely and accurate reporting. The facility's failure to report these incidents as required constituted a deficiency in protecting residents' rights and ensuring their safety.