Failure to Timely Report Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made to the administrator and to the State Survey Agency, as required by policy and regulation. Specifically, two residents were involved in separate incidents where timely reporting did not occur. One resident with multiple diagnoses, including chronic obstructive pulmonary disease, schizophrenia, and acute kidney failure, was found in bed with a laceration to the back of the head. The injury was classified as of unknown origin, and the resident was unable to communicate about the incident due to cognitive impairment. The incident was discovered by a CNA, and although the resident was sent to the hospital for treatment, the facility did not report the injury to the State Survey Agency within the required 2-hour timeframe, instead reporting it the following day. In a separate incident, another resident with significant cognitive and behavioral issues, who required one-on-one care, was involved in an episode where a CNA was overheard raising his voice and using inappropriate language after the resident grabbed his wrist. The agency LPN who overheard the incident did not report it to the DON immediately or within 2 hours, and the DON subsequently delayed reporting to the administrator. The administrator also failed to submit a report to the State Survey Agency within the required 2-hour window. These failures were confirmed through interviews and record reviews.