Failure to Timely Report Allegations of Abuse and Misappropriation
Penalty
Summary
Facility staff failed to report allegations of misappropriation and abuse to the required agencies within the mandated timeframes for three residents. In one case, a resident reported missing money from his bedside drawer after being moved to a different room. The incident was documented in the clinical record, and an internal investigation was initiated, but the allegation was not reported to the state survey agency, adult protective services, or the ombudsman until four days after the initial report, exceeding the required reporting period. In another instance, two residents were involved in an altercation resulting in physical abuse. The clinical record indicated that one resident, who had a diagnosis of traumatic brain injury, hit another resident and exhibited threatening behavior toward staff. Emergency services were called, and the resident was sent to the hospital for evaluation. Despite the seriousness of the incident, the facility did not report the event to the appropriate agencies until more than eight hours after it occurred, which was outside the two-hour reporting requirement for abuse allegations. Interviews with facility staff, including the DON, confirmed that the facility's process for reporting such incidents did not align with the policy requirements, which mandate immediate reporting—no later than two hours for abuse or bodily injury and no later than 24 hours for other incidents. Facility policies reviewed by surveyors clearly outlined these requirements, but the staff failed to adhere to them in the cases identified.