Failure to Timely Report Alleged Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report allegations of abuse and an injury of unknown origin to the State Agency within the required timeframe for a resident who was moderately cognitively impaired and dependent on staff for most activities of daily living. The resident's family filed a grievance indicating that a nursing assistant was aggressive with the resident, and a nurse later discovered bruising on the resident's upper arm that resembled finger marks. Despite these events, neither the allegation of aggression nor the unexplained bruising was reported to the State Agency as required by facility policy and federal regulations. The resident had significant physical and cognitive limitations, including hemiplegia and polyneuropathy, making her particularly vulnerable. Documentation showed that the resident required maximum assistance and was always incontinent, with a history of stroke and related impairments. The care plan did not identify the resident as being at risk for abuse, and the event history did not document the bruising incident. Interviews with family members revealed ongoing concerns about aggressive care and changes in the resident's mental and physical state, including expressions of distress and a desire not to live if care continued to be painful. The family only learned of the bruising after inquiring, and the DON was unable to explain the cause, suggesting possible improper transfer techniques but not reporting the incident. Staff interviews indicated a lack of awareness and understanding regarding mandatory reporting requirements for abuse allegations and injuries of unknown origin. Nursing staff who observed or were informed of the bruising did not escalate the issue to management or report it externally, relying instead on documentation in the medical record. The DON and other staff did not recognize the need to report the incident, believing that internal interventions were sufficient. The facility's policy clearly outlined the obligation to report such events within two hours if abuse or serious injury was involved, but this protocol was not followed in this case.