Failure to Timely Report Alleged Abuse and Submit Investigation Findings
Penalty
Summary
The facility failed to timely report an allegation of sexual abuse to the State Survey Agency (SSA) and failed to submit investigation findings for multiple abuse-related events within required timeframes. For one resident, behavior progress notes documented that the resident had repeatedly been removed from female residents' rooms and had been rubbing the legs of other female residents, with staff repeatedly correcting and educating him on inappropriate behavior. A staff member later identified that this behavior should have been reported as a reportable event to the SSA but had not been. In a specific incident, a staff member observed this resident placing his hand on another resident's thigh while assisting her with eating, asked him to remove his hand, and reported the behavior to the nurse on duty after it recurred. The nurse documented the behavior in the resident's behavior charting but did not report the allegation to the SSA, despite having received training on forms of abuse and reporting requirements. The facility also failed to submit investigation findings to the SSA within the required five working days for several previously reported events. One facility-reported event involved a verbal altercation between two residents, for which the investigation findings were due to the SSA by a specified date but were submitted one day late. Another facility-reported event involved a resident's allegation of verbal abuse by a staff member, where the investigation findings were also submitted one day past the due date. The administrator reported that an Administrator in Training was responsible for submitting reportable events and investigation findings and that alerts were received when findings were due, but could not explain why the findings were submitted late. These actions and inactions were inconsistent with the facility's Abuse, Neglect, and Exploitation policy, which required reporting allegations of abuse to appropriate agencies within specified timeframes and reporting investigation results within five working days of the incident, as required by state agencies.
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