Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of an alleged abuse incident to the State Agency (SA) as required by regulation and its own policy. The facility’s “Misconduct Investigation and Reporting” policy required staff to immediately report incidents to a nurse or supervisor, for the nurse/supervisor to immediately notify the Administrator after ensuring resident safety, and for any allegation involving abuse or resulting in serious bodily injury to be reported within two hours of discovery. Resident 2, who had dementia, anxiety disorder, and severe cognitive impairment (BIMS score of 3/15) and was mobile with a walker, was involved in an incident in which another resident pinched their arm. Nursing documentation for Resident 2 on the date of the incident showed that the DON and social worker were updated at 3:00 PM, and the care plan was revised the same day to keep Resident 2 an arm’s length away from Resident 1. Resident 1 had cerebral palsy, seizures, and moderate cognitive impairment with short- and long-term memory loss. The facility’s Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report showed the report was submitted to the SA at 8:50 PM on the date of the incident. During interview, RN1 stated she became aware of the pinching incident sometime after breakfast and reported it to management but could not recall the exact time. The DON stated that such incidents are typically reported within two hours and that the Administrator manages reporting to the SA. The Administrator stated that incidents with injuries or serious injuries must be reported to the state within two hours and characterized this incident as not involving serious injuries but still subject to the two-hour reporting requirement. The Administrator confirmed the initial report to the SA was made at 8:50 PM and acknowledged, after reviewing the facility policy, that the incident should have been reported within two hours.
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