Failure to Timely Report Allegations of Abuse and Injuries
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or injury of unknown origin to the regulatory agency, the Office of Health Care Quality (OHCQ), within the required 2-hour timeframe for three residents. In one case, a non-verbal, cognitively impaired resident was found with a laceration to the right thumb, but the incident was not documented or reported by the LPN on duty, and facility administration only became aware the following day. The self-report to OHCQ was sent more than 24 hours after the injury was discovered. In another instance, a resident with multiple complex medical conditions, including tracheostomy, G-tube, diabetes, hemiplegia, and ventilator dependence, was found to have a dislocated shoulder. The injury was confirmed, but the report to OHCQ was not made until the following day, exceeding the 2-hour reporting requirement. A third incident involved an allegation of physical abuse by a GNA, reported by a resident's spouse. The DON was not notified until the next morning, and the initial report to OHCQ was sent several hours after the required timeframe. Documentation from staff revealed inconsistencies in awareness and reporting of the alleged abuse. In all three cases, the DON confirmed the findings of late reporting during interviews, although the DON was not employed at the facility at the time of the incidents.