Failure to Timely Report Suspected Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to comply with regulatory requirements for timely reporting of suspected abuse, neglect, or injuries of unknown origin to the State Survey Agency. Multiple instances were identified where residents with cognitive and physical impairments, including those with severe dementia and total care needs, were found with unexplained bruises or injuries. In several cases, there was no documentation of a fall or incident to account for the injuries, and the facility did not submit required incident reports to the state agency. For example, one resident with severe cognitive impairment was found with multiple bruises aligning with equipment and furniture, but no report was made to the state agency. In another case, a resident who required substantial staff assistance for transfers was found with a new bruise, but the facility's investigation did not determine the cause, and the injury was not reported to the state agency. Interviews with staff revealed a misunderstanding of reporting requirements, with some staff believing that if a plausible explanation could be found, reporting was unnecessary, even without corroborating evidence. The facility's social service coordinator confirmed that no reportable injuries had been submitted to the state agency for an extended period. Additional deficiencies included late reporting of an abuse allegation and failure to report injuries of unknown origin for other residents, despite facility policy requiring prompt reporting. The facility's policy did not align with state regulations, as it did not require all injuries of unknown origin to be reported within two hours. Interviews with nursing leadership confirmed a lack of documentation and reporting for these incidents, and the Director of Nursing acknowledged that the required reports had not been made.