Failure to Timely Report Multiple Allegations of Resident Abuse
Penalty
Summary
The facility failed to timely report two separate allegations of abuse involving a cognitively impaired resident, Resident C, in accordance with its abuse, mistreatment, neglect, and exploitation policy. Resident C had diagnoses including Alzheimer's disease, dementia, seizures, weakness, and depression, with a quarterly MDS showing severe cognitive impairment and dependence on substantial assistance for most ADLs. Her care plan noted a preference for video recording in her room and a STOP sign across the door frame, with interventions to protect privacy. On one occasion, an incident report (Facility Incident #236) was submitted for an event in which a male resident entered Resident C's room and sat on her bed; however, the facility's later review revealed that an earlier, more serious incident involving the same resident entering her room, exposing himself, and sitting on her chest and shoulder had been reported by the responsible party via email but was not reported to the State Agency as required. The record further showed that another incident (Facility Incident #254) involving a different resident, Resident D, climbing into bed with Resident C after undressing and wiping her genital area with Resident C's blanket was also not reported to the State Agency at the time it occurred. The responsible party had emailed the previous administrator about this event as well, but no report was filed until months later, when the current Administrator became aware that the prior incident had never been reported. The facility’s abuse policy required that all alleged violations reported by residents, relatives, or care plan members be immediately reported to the Administrator and to the Department of Health within specified time frames (2 hours for alleged abuse and no later than 24 hours for all other allegations). The Administrator acknowledged awareness of the allegations from September and October and stated he had assumed the previous administrator had reported them, but they had not been reported in accordance with the policy and regulatory requirements.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.