Failure to Timely Report Abuse, Neglect, and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin and allegations of abuse and neglect immediately to the Resident Advocate (RA) and within two hours to the State Survey Agency (SSA) for three residents reviewed for abuse and neglect. According to the facility's policy, all such incidents should be reported immediately, but not later than two hours if serious bodily injury is involved, or within 24 hours if not. However, in each of the three cases, there were significant delays in reporting. For one resident with severe cognitive impairment and total dependence on staff for activities of daily living, an incident occurred where a CNA allegedly forcefully handled the resident during care, causing the resident to cry out in pain. The CNA who witnessed the event did not report it to the nurse until nearly seven hours later, and the incident was not reported to the RA or SSA until many hours after that. The initial report submitted to the SSA was blank and did not contain any information regarding the allegation. Another resident with severe cognitive impairment and a history of fractures was found with multiple bruises of unknown origin. The bruising was identified by staff, but the initial report to the SSA was not submitted until approximately five hours after discovery. In a third case, a resident with hemiplegia and vascular dementia was found in a saturated brief and bedding, leading to an allegation of neglect. The incident was reported to the administrator and RA with significant delays, and the SSA was not notified until 18.5 hours after the initial allegation. In all cases, staff and administration interviews confirmed that reporting did not occur within the required timeframes.