Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that all alleged violations involving mistreatment, neglect, abuse, or misappropriation of resident property were reported immediately, but not later than two hours if the alleged violation involved abuse or resulted in serious bodily injury. Specifically, an allegation of abuse made by a resident was not reported to the State Agency within the required timeframe. The resident, a female with diagnoses including gastrostomy malfunction, COPD, type 2 diabetes, unspecified dementia, and cellulitis of the abdominal wall, reported to the DON that a medication aide had pinched her mouth and attempted to force medication after she refused it due to its taste. The resident's family was present at the time of the allegation. Upon receiving the allegation, the DON filed a grievance, suspended the medication aide pending investigation, and completed life satisfaction surveys for abuse and neglect. The DON reported the incident to the facility's abuse coordinator (the Administrator) and the corporate office. However, after an internal investigation and consultation with the corporate office, it was determined that the incident was not reportable to the State Agency, as there was a witness present and the family later suggested the resident may have been confused due to dementia. As a result, the incident was not reported to the State Agency as required by regulation. Interviews with facility staff confirmed awareness of the two-hour reporting requirement for abuse allegations. The Administrator acknowledged that the incident was not reported to the State Agency based on corporate guidance and the internal investigation's findings. Facility records showed that in-service training on abuse and neglect was conducted after the incident, but the initial failure to report the allegation within the mandated timeframe constituted a deficiency.