Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported to the state agency within the required two-hour timeframe. The incident involved a resident who reported that a night nurse entered her room while she was on the toilet and attempted to administer medication without identifying himself or knocking. The resident expressed feeling scared and shaken by the encounter, and later reported that the nurse made a comment implying he would withhold medication in the future. The resident communicated her distress to a certified nursing assistant (CNA), who consoled her but did not witness the incident. The facility's policy requires that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported immediately, but not later than two hours after the allegation is made, especially if the event involves abuse or results in serious bodily injury. In this case, the resident informed the social worker of the incident the following evening, who then relayed the information to the nursing home administrator. The administrator and director of nursing took immediate steps to suspend the nurse and begin an investigation, but the report to the state agency was not submitted until nearly 24 hours after the facility became aware of the allegation. The resident involved had a history of chronic obstructive pulmonary disease, hypertension, and hypothyroidism, and was assessed as cognitively intact. The delay in reporting was attributed to the CNA not immediately reporting the resident's disclosure of the incident, as well as the timeline of communication between staff members. The deficiency was identified based on interviews and record reviews, which confirmed that the facility did not adhere to its own policy or regulatory requirements for timely reporting of abuse allegations.