Failure to Timely Report Alleged Abuse and Injuries of Unknown Origin
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 four residents. In one instance, a resident reported to a family member that a nurse caused injury resulting in swelling to the right hand, but the incident was not reported to OHCQ until more than 24 hours after the facility was notified. Another case involved an allegation related to a staff meeting recording, with the initial report to OHCQ submitted nearly two weeks after the incident. For a third resident, bruising of unknown origin was discovered while the resident was in the emergency room, but the incident was not reported to OHCQ, nor was an investigation conducted. In the fourth case, a resident alleged that an aide threw water in their face after administering medication, but the report to OHCQ was delayed by several days. Interviews with the Director of Nursing (DON) confirmed the late reporting or lack of reporting in these cases. Documentation reviewed by surveyors, including email confirmations and investigative packets, substantiated that the facility did not adhere to the required reporting timelines for suspected abuse or injuries of unknown origin. The findings were based on reviews of facility-reported incidents, complaint investigations, and staff interviews.