Failure to Timely Report Abuse Allegations and Investigation Results
Penalty
Summary
Facility staff failed to report allegations of abuse within the required timeframes as outlined in the facility’s Abuse, Neglect, and Exploitation policy and federal requirements. The policy, last revised in 11/2023, required that all alleged violations reported by a resident, staff, or family be reported to the Administrator, state agency, adult protective services, and other required agencies immediately, but no later than 2 hours after the allegation is made. For one incident, a resident reported to an RN that a GNA rolled the resident over in bed and hit the resident’s head on the bedrail. The RN did not report this allegation of abuse to the DON until approximately 11 hours later, and the DON then reported the allegation to the State Agency after she became aware of it. The DON stated that the nurse was unsure it was an allegation of abuse and confirmed that her expectation was that staff report allegations as soon as possible. In a separate incident involving another resident, the facility submitted an initial allegation of abuse to the State Agency and was required to submit the final investigation results within 5 working days. The final 5‑day report was submitted one working day late, beyond the required 5‑day timeframe. During an interview, the DON acknowledged that the timeframe for submitting follow‑up investigation results to the State Agency is 5 days. These failures to report the initial allegation within 2 hours and to submit the final investigation report within 5 working days constituted noncompliance with the facility’s own policy and reporting requirements.
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