Failure to Recognize and Report Suspected Abuse Following Resident Injury
Penalty
Summary
The facility failed to recognize and report an injury of unknown origin as a suspected allegation of abuse for a resident with a complex medical history, including dementia, a prior left humerus fracture, and other chronic conditions. On the morning in question, a certified nursing assistant observed the resident guarding her left arm and expressing pain when touched, with a noticeable green bruise and abnormal arm movement. There was no prior report of a fall, and the incident was not communicated during shift change. Pain medication was administered, and an x-ray was ordered, but the resident was ultimately sent to the emergency room, where a comminuted and impacted fracture of the left humeral head was diagnosed. Interviews revealed that a family member had observed two agency aides handling the resident roughly during morning care via a room camera, specifically pulling on the resident's contracted left arm and thigh to turn her, which caused the resident to cry out in pain. The family member reported this observation to an LPN, who did not escalate the concern to management, believing the action was not malicious. The family member also showed video evidence of the incident to the DON, ADON, and other staff, who acknowledged that the aides' handling was inappropriate and contrary to proper transfer techniques for the resident's condition. Despite these observations and reports, the incident was not initially treated as a suspected abuse case or reported to the administrator as required by facility policy. The administrator was not informed until after the fact, and the incident was not viewed as abuse by some members of the leadership team. Facility policies require that injuries of unknown origin and allegations of abuse be reported and investigated according to established procedures, but these protocols were not followed in this case.