Failure to Timely Report Abuse, Neglect, and Injuries of Unknown Origin
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, and injuries of unknown origin to the State Agency as required by regulation. In one instance, a resident with hemiplegia and multiple comorbidities was found with discoloration around the left eye, which was identified as an injury of unknown origin. Although the injury was assessed by nursing staff and the responsible party and provider were notified, the incident was not reported to the State Agency. Both the LPN and the Nursing Supervisor acknowledged that the injury should have been classified as an injury of unknown origin and reported, but this did not occur. In another case, a resident-to-resident altercation occurred when one resident, with a history of agitation and aggression, punched another resident in the face in the dining room. The incident was witnessed and reported to an LPN, who assessed the involved residents and notified the provider and responsible party. However, the altercation was not reported to the State Agency until over 17 hours after the event, well beyond the required reporting timeframe. The DON stated that the delay was due to not being made aware of the incident until the following day. Additionally, four residents with varying degrees of cognitive impairment and incontinence did not receive timely incontinent care. The incident was identified by an LPN, who found multiple residents in need of care, and it was later determined that care had not been provided for an extended period. Although the supervisor was made aware of the neglect, the State Agency was not notified until nearly two days after the facility became aware of the situation. Facility policy and staff education materials indicated that such allegations should be reported immediately to supervisors and to the State Agency within two hours, but this protocol was not followed in these cases.