Failure to Submit Required 5‑Day Abuse Investigation Report to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to submit a complete 5‑day written investigation report to the State Survey Agency (DHSR) within 5 working days following an allegation of employee‑to‑resident abuse, as required by facility policy. The facility’s abuse/neglect/misappropriation/crime reporting policy required the Administrator to thoroughly investigate and file a complete written report to the State Agency within 5 working days, including specific details such as the date of occurrence, names of the resident and staff involved, description and location of any injury, description of the occurrence, immediate protective actions, prevention mechanisms, and documentation of reports to outside agencies. Despite this policy, the 5‑day investigation report associated with an allegation of employee‑to‑resident abuse for one resident was not received by DHSR. The incident began when a resident, identified as severely cognitively impaired and disoriented, reported that he had been “beat up” by a staff member the previous evening. The initial allegation report submitted to DHSR documented that the resident could not identify the staff member involved, that a head‑to‑toe skin assessment revealed no signs of injury, and that there were no details of physical or mental injury or harm. The facility became aware of the allegation the following day, submitted the initial allegation report to DHSR within hours, and notified law enforcement. The resident’s EMR included a Medical Director note indicating the resident reported being beaten, had baseline intermittent confusion and agitation toward staff, and that nursing staff reported he liked to roll out of bed and scream for help. Subsequently, DHSR sent an email to the Administrator and DON stating that the 5‑day investigation report had not been received and requesting that it be faxed as soon as possible. The Administrator later stated she could not locate this email, had no records of fax transmittals for the 5‑day report, and acknowledged the report was not sent to DHSR. A 5‑day investigation summary dated within the required timeframe was found in the facility’s internal folder, documenting that the allegation could not be substantiated, that body audits and interviews were conducted on the hallway, and that no issues were noted. However, this internal summary did not identify the staff member who reported the allegation and did not include any witness statements. Both the Administrator and DON were unable to recall who initially reported the allegation, and the DON acknowledged that submission of the 5‑day report to DHSR may have been missed, resulting in noncompliance with the facility’s own reporting requirements and state reporting expectations.
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