F0607

D

Failure to Implement Abuse Policy for Timely Reporting and Resident Protection

Baltimore, Maryland Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy as written, specifically regarding timely identification, reporting, and protection of residents following an abuse allegation. The facility’s policy, last reviewed/revised in 11/2023, stated that any report by a resident, staff, or family was to be considered an abuse allegation, that an immediate investigation was warranted when there was suspicion of abuse, that room or staffing changes were to be made if necessary to protect residents from an alleged perpetrator, and that all alleged violations were to be reported to the Administrator, state agency, adult protective services, and other required agencies immediately, but no later than 2 hours after the allegation was made.

Record review of a facility-reported incident showed that a resident reported to an RN that a GNA rolled the resident over in bed, causing the resident’s head to hit the bedrail. This allegation was made at 8:30 PM, but the Administrator was not informed until approximately 11 hours later, at 7:30 AM the following day, and the DON was not informed until about 7:00 AM. The report to the state agency was submitted at 9:25 AM, exceeding the policy’s 2-hour reporting requirement. During interview, the DON stated that the RN reported she was unsure whether this was an abuse allegation and did not call immediately, despite staff being aware they could contact the DON at any time. Additionally, the alleged perpetrator GNA continued to work the remainder of the shift until 11:00 PM with vulnerable residents, contrary to the policy’s requirement to make staffing changes as necessary to protect residents from the alleged perpetrator.