Failure to Timely Report Investigation Results of Abuse and Injury Allegations
Penalty
Summary
The facility failed to report the results of all investigations of alleged abuse, neglect, or injury of unknown origin to the administrator or designated representative and to the State Survey Agency within 5 working days, as required by regulation and facility policy. Specifically, for three separate incidents involving allegations of inappropriate touching and an injury of unknown origin, the Provider Investigation Reports (Form 3613-A) were completed in the facility's electronic medical record system but were not submitted to the Texas Unified Licensure Information Portal (TULIP) within the required timeframe. The Assistant Director of Nursing (ADON), who was responsible for submitting these reports, believed the electronic system would automatically upload the reports, but later realized manual submission was necessary. The first two incidents involved a male resident with diagnoses including mood disorder, dementia, and high risk of heterosexual behaviors, who was alleged to have inappropriately touched two female residents. Both female residents had significant cognitive or physical impairments, including spina bifida, anxiety disorder, depressive episodes, diabetes, stroke, and aphasia. Immediate actions were taken by administration and clinical staff, and thorough investigations were completed, but the results were not timely reported to the State Survey Agency as required. The third incident involved a female resident with Alzheimer's disease, Parkinson's disease, and severe cognitive impairment, who sustained an injury of unknown origin resulting in a hip fracture and other medical complications. Although the investigation was completed and documented, the results were not uploaded to the TULIP system within the mandated 5-day period. Interviews with the ADON and Administrator confirmed the oversight and misunderstanding regarding the submission process, which led to the deficiency.