Failure to Report Injury of Unknown Origin and Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report two separate incidents as required by its Abuse Prevention and Prohibition policy. In the first incident, a resident with severe cognitive impairment was found with a bruise of unknown origin to the right periorbital area. The resident was unable to provide a history of the injury, and there was no documented evidence of a witnessed fall or explanation for the bruise. Despite the lack of a known cause, the administrator and regional administrator did not submit a report to the State Survey Agency, as required for injuries of unknown origin. In the second incident, another resident with severe cognitive impairment was physically pulled from a wheelchair and yelled at by another resident. This event was documented in the facility's incident log and nurse's notes, but there was no evidence that the incident was reported to the State Survey Agency as an allegation of resident-to-resident abuse. Interviews with facility leadership confirmed that the incident was not reported, and there was uncertainty among staff about whether the event constituted a reportable allegation of abuse.