Failure to Timely Report Alleged Abuse Between Residents
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents within the required 24-hour timeframe. Specifically, one resident with severe cognitive impairment and a history of sexually inappropriate behavior was observed by two other residents to have inappropriately touched another cognitively impaired resident in the dining room. The incident was witnessed by two residents, one of whom immediately reported it to an LVN present at the nurses' station. The LVN responded by removing the resident from the dining room and assessing the alleged victim for injury, finding none. Despite being aware of the allegation, the LVN did not document the incident in the progress notes or report it to the facility's Administrator or DON. The LVN stated she did not know why she failed to report the incident, despite having been previously in-serviced on recognizing, preventing, and reporting abuse, neglect, and exploitation. The Administrator and DON both confirmed they were unaware of the incident until informed by the surveyor during the investigation. Record reviews confirmed that both residents involved had severe cognitive impairment and required extensive assistance with daily activities. The facility's policy required all allegations of abuse, neglect, exploitation, or mistreatment to be reported and investigated within federal timeframes, but this process was not followed in this case. The failure to report the incident as required constituted a deficiency in the facility's abuse reporting procedures.