Failure to Timely Report Abuse Allegations and Misappropriation of Medication
Penalty
Summary
The deficiency involves the facility’s failure to timely report allegations of abuse and misappropriation of resident property to the state agency (SA) within required timeframes, and incomplete documentation of when and to whom the allegations were reported. For one resident, documentation showed a care plan meeting note initiated by a unit manager on one date was incomplete, and a late-entry care plan note by the Social Services Director (SSD) indicated the care plan meeting occurred earlier that same day. The facility’s investigation file for this incident documented that the resident accused two male therapists of kicking the resident in the chest and stomach, and that staff became aware of the allegation at 4:00 PM, but failed to document to whom it was reported. The final investigation report indicated the allegation was reported by a family member during a care plan meeting. The SSD’s written statement did not include the date and time she was told of the allegation, nor when and to whom she reported it. Email confirmation showed the allegation was reported to the SA at 5:55 PM that day. In interview, the ADON stated she documented the date and time she became aware of the allegation on the initial report form and acknowledged she should have documented the date and time the SSD was told of the allegation but did not. The SSD reported in interview that the care plan meeting occurred at 2:30 PM, lasted about 45 minutes, and that she reported the allegation to the ADON between 3:19 PM and 3:30 PM. A second deficiency involved the facility’s failure to timely report a misappropriation of resident medication, which is classified as a form of abuse. The facility-reported incident showed that staff member #4 made the facility aware of the concern on one date, but the SA was not notified until eight business days later at 6:00 PM. Initially, during interview, the DON stated this was considered an unusual circumstance; however, after surveyor review and interviews, the incident was classified as misappropriation of resident medication. The survey team requested email confirmations of submissions to verify reporting timeframes and reviewed concerns about reporting timeframes throughout the survey and again during exit.
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