Failure to Timely Report Alleged Abuse and Injury of Unknown Origin
Penalty
Summary
A deficiency occurred when the facility failed to report an allegation of abuse involving a resident who sustained a fracture of the tibia and fibula while receiving care from an agency CNA. The incident took place during a brief change, when the resident's right leg came off the mattress and hit the floor, as described by the resident. The resident reported pain and fear following the incident, but did not immediately notify the nurse due to concerns about the CNA's reaction. The resident later informed a nurse the next day, and subsequently reported increased pain to the Nurse Manager several days later. The clinical record indicated that the resident had a history of orthopedic issues, including a previous lumbar vertebra fracture and was dependent on staff for bed mobility and transfers, requiring two-person assistance and a mechanical lift. Despite the resident's complaints of pain and the change in condition, the Nurse Manager was not notified until several days after the incident, and the Administrator (Abuse Coordinator) was not informed until after the x-ray confirmed the fracture. The facility's own documentation confirmed that the resident's complaints were known to nursing staff prior to the Administrator being notified. The facility's policy required immediate reporting of all allegations of abuse, neglect, or injuries of unknown source to the Administrator and State Survey Agency, but this was not followed. The delay in reporting was acknowledged by facility leadership during interviews, with the Administrator noting that the Nurse Manager should have reported the concern when first made aware. The failure to report the incident in a timely manner constituted noncompliance with federal requirements for reporting alleged violations.
Plan Of Correction
F609 Reporting of Alleged Violations It is the practice of the facility to ensure that all allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury. If the events do not involve abuse and do not result in bodily injury, reporting is required not later than 24 hours to the administrator and other officials in accordance with state law through established procedures. Element 1: Resident 406 remains in the facility and continues to receive supportive visits for psych services. The plan of care was updated, and she. The contracted CNA involved in the incident no longer works at the facility. All residents residing in the facility can be affected by this cited practice. Residents with BIMS scores of 12 or higher have been interviewed to identify concerns with abuse. Potential allegations identified will be reviewed through the abuse prevention process. Residents with BIMS scores of 11 or lower will also be assessed for signs and symptoms of abuse. Potential allegations identified will be reviewed through the abuse prevention process. Element 2: The interdisciplinary team reviewed the abuse policy and deemed it appropriate for use as written. The facility staff were educated on the abuse policy; in addition, the administrator and DON educated staff with an emphasis on the reporting within the 2-hour window and what constitutes abuse. The facility staff will be in-serviced on types of abuse at each monthly in-service for the next 3 months to provide additional education. Element 3: The IDT will randomly interview residents and staff regarding allegations of abuse weekly for 4 weeks, then monthly for 3 months. Any allegations of abuse will be immediately reported to the administrator for investigation and reporting. The administrator/designee will bring allegations of abuse investigations to the QAPI meeting to ensure compliance with the abuse process, including timely reporting and investigation. Element 4: The administrator/designee is responsible for compliance: date of compliance May 6, 2025.