Failure to Report Suspected Abuse and Neglect to Authorities
Penalty
Summary
The facility failed to report two separate incidents involving suspected abuse and neglect to the appropriate authorities as required by policy and regulation. In the first incident, a resident with severe mental impairment physically assaulted his roommate, who also had significant cognitive impairment, by hitting him with a water mug while the roommate was in bed. The assaulted resident sustained cuts, bruises, and a scratch, requiring evaluation and treatment at an emergency room. Although the incident was reported to the State Survey Agency, there was no notification to local law enforcement, contrary to facility policy and federal requirements. Documentation confirmed that the Nursing Home Administrator decided not to notify the police due to the mental condition of the residents, despite acknowledging that policy did not provide an exception for mental capacity. In the second incident, another resident, who was on hospice care and had dementia and metabolic encephalopathy, sustained a second-degree burn to his right thigh from a hot liquid spill. The injury was significant, with redness, blisters, and open areas measuring several centimeters. The Assistant Director of Nursing provided the resident with coffee, and shortly after, the resident was found with the spilled coffee and a burn on his thigh. The incident was not reported to the State Survey Agency, and there was no incident or accident report created at the time. The Director of Nursing, who started after the incident, was unaware of the event until later and confirmed that the injury was not reported as required. Both incidents demonstrate a failure to follow the facility's abuse and neglect reporting policy, which mandates immediate reporting of suspected abuse, neglect, or injuries of unknown source to the State Survey Agency and local law enforcement. Interviews with facility leadership confirmed awareness of the incidents and the lack of required reporting, with no justification found in policy for the omissions. The deficiencies were identified through record review and staff interviews, with documentation supporting the lack of timely and appropriate notification to authorities.