Failure to Timely Report and Failure to Report Allegations of Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report, and in one case to report at all, allegations of abuse to the state oversight agency. In the first incident, a facility-reported incident file showed that a resident reported an allegation of abuse to a physical therapy assistant at 10:00 AM on 3/17/25. The initial report to the Office of Health Care Quality (OHCQ) was not sent until 2:13 PM the same day, more than four hours after the allegation was first reported to staff. The Nursing Home Administrator (NHA), who served as the facility’s abuse coordinator, acknowledged that the regulatory reporting clock starts as soon as any staff member is made aware of an allegation and that the facility had a two-hour reporting requirement. The NHA confirmed that the allegation was not reported within the mandated timeframe. During interview, the NHA initially stated that the delay occurred because the physical therapy assistant reported the allegation to the director of rehab, who then reported it to her. However, further review of the investigation packet showed that the assistant had directly reported the allegation to the NHA, contradicting the NHA’s explanation. The NHA also stated that the assistant had been educated to report allegations of abuse immediately. These records and interviews established that the facility did not meet the required timeframe for reporting the allegation of abuse to OHCQ, despite the NHA’s awareness of the reporting standard and her role as abuse coordinator. In the second incident, a grievance form documented that a cognitively intact roommate reported observing a GNA provide abrupt and rough care to a resident with severe cognitive impairment, dementia, and a cognitive communication deficit, who required total assistance with personal hygiene and extensive assistance with turning and repositioning, and was unable to use the call bell. The roommate reported that the GNA entered the room in a poor mood, became frustrated with the resident’s inability to cooperate, grabbed the resident hard, spoke angrily, and used force when laying the resident back down and moving the resident’s legs onto the bed. The roommate reported these concerns to the facility social worker the same morning. The social worker stated that the concern was reviewed by the NHA, who asked the reporting resident if they thought the incident was abuse; when the resident said no, the NHA determined it was not abuse and did not report it to OHCQ. In a subsequent interview, the NHA confirmed that she did not report this allegation because she concluded it did not meet the definition of abuse, despite acknowledging that all allegations of abuse were supposed to be reported.
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