Failure to Timely Report Alleged Abuse and Serious Injury
Penalty
Summary
The facility failed to ensure timely reporting of alleged abuse and serious injury to the state agency as required by regulations. In one instance, a male resident with dementia and physical impairments reported to the DON that two CNAs were rough with him during care, including an allegation that one CNA struck him with a rolled-up rag and knocked a scab off his foot. Although the Administrator conducted an internal investigation and determined the accused CNAs were not present at the time of the alleged incident, the facility did not report the allegation to the state agency as required, since the Administrator believed reporting was unnecessary if the accused staff were not present. In a separate case, another male resident with dementia and a history of falls experienced an unwitnessed fall resulting in a head injury. The resident was found on the floor with a hematoma and was transported to the hospital, where he was diagnosed with a subdural hematoma. Despite the serious nature of the injury, the facility did not report the incident to the state agency. The DON, who was present at the time of the fall, confirmed that the Administrator was responsible for reporting such incidents, but the required report was not made. Review of the facility's own policy confirmed that all allegations of abuse, neglect, exploitation, or injuries of unknown source must be reported immediately to the Administrator and to authorities, with specific timelines based on the severity of the incident. The facility's failure to report both the abuse allegation and the serious injury was not in accordance with their policy or regulatory requirements.