Failure to Report Allegations of Neglect and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report allegations of neglect and injuries of unknown origin to the administrator and the state survey agency for three residents. According to the facility's own Abuse Prevention and Reporting policy, staff are required to immediately report any allegations or suspicions of abuse or neglect to the administrator, and to notify the state survey agency within specified timeframes depending on the severity of the incident. However, in the cases reviewed, these procedures were not followed. For one resident with severe cognitive impairment and incontinence, staff made derogatory remarks about the resident's past, and there were allegations that a CNA delayed care due to these remarks. The administrator was not made aware of these concerns until the surveyor's interview, and the incident was not reported or investigated as required. In another case, a resident with memory impairment and behavioral issues was found with unexplained bruising and swelling around the eye. The cause of the injury was not witnessed, the resident could not explain it, and the investigation was limited to a few staff interviews. The injury was not reported to the administrator or the state survey agency as an injury of unknown origin. A third resident, who had moderate cognitive impairment and a recent history of hospitalization for a blood disorder, was observed with significant facial bruising. The cause of the bruising was not documented, and there was no investigation or reporting to the administrator or state survey agency. In all three cases, the facility did not follow its own policy for reporting and investigating allegations of neglect or injuries of unknown origin, resulting in a failure to protect resident rights and ensure proper oversight.