Failure to Timely Report Alleged Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner and did not report an injury of unknown origin as required. In the first instance, a resident reported to the administrator that another resident might have been choked by a Geriatric Nursing Assistant during the evening shift. Documentation showed that a Certified Medicine Aide was informed by a resident and received a note from a roommate about the alleged abuse, but failed to notify a supervisor, resulting in a delay in reporting the incident to the state agency. The administrator acknowledged that the incident was not reported within the required two-hour timeframe due to this failure in communication. In the second instance, a non-verbal, fully dependent resident with severe contractures was found to have a swollen, red, and warm left ankle, and subsequent imaging revealed fractures of the left tibia and fibula. There was no documentation of any accident or trauma associated with the injury, and the resident was incapable of moving independently. The facility did not report this injury of unknown origin to the state agency, as the medical director determined it was a pathological fracture two days after the injury was identified. The DON confirmed that the injury was not reported because of this determination, despite the initial lack of explanation for the injury.