Delayed Reporting of Alleged Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse involving Resident #4 to the State Agency within the required regulatory timeframe. Resident #4 had dementia with cognitive impairment, as evidenced by a BIMS score of 02, and a history of behavioral symptoms that interfered with care and participation in activities. The resident’s care plan noted a potential for behaviors and directed staff to allow time for the resident to respond to directions due to dementia. An allegation of abuse involving this resident occurred on the evening of February 8, 2026, between approximately 11:30 P.M. and midnight. LPN/Staff #34, who was working the 6:00 P.M. to 6:30 A.M. shift when the alleged abuse occurred, did not report the allegation to the administrator before going home after her shift. She later stated she was in shock and that there was a lot going on at the time, and she believed she had 24 hours to report the suspected abuse. She returned to the facility and reported the allegation to the Administrator/Staff #29 around 2:00 P.M. on February 9, 2026, more than 12 hours after the incident. Interviews with another LPN (Staff #10), the Administrator, and the DON/Staff #22 confirmed that staff receive regular abuse training and that facility policy and expectations require all allegations or suspicions of abuse to be reported to the Administrator or designee immediately, and to the State Agency immediately after ensuring resident safety. The delay in reporting by Staff #34 did not meet the facility’s policy or the DON’s expectations.
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