Failure to Timely Report Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report allegations of resident-to-resident abuse and injuries of unknown origin to the State Survey Agency as required. In one instance, a resident was found to have fading bruising on the left lower back with no documented falls or injuries in the preceding weeks, and the cause of the bruising was not identified. Staff were unaware of the bruising, no investigation was completed, and the incident was not reported as required. Later, the same resident sustained a fractured hip after a fall that was not witnessed, and the resident was an unreliable reporter. This major injury of unknown origin was also not reported to the State Survey Agency. In another case, a resident was agitated and allegedly hit her roommate, as reported by the roommate, though the incident was not witnessed by staff. The facility investigated the event but determined it was not abuse and did not report the allegation to the State Survey Agency. The facility's policy requires all allegations, including those not yet investigated, to be reported to the administrator and the State Survey Agency, but these incidents were not reported in accordance with policy.