Failure to Timely Report Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft, as well as the results of related investigations, to the proper authorities for multiple residents. In one case, a staff member overheard a resident accuse another staff member of causing pain and using inappropriate language, but the report was not made until the following day. The investigation could not confirm or refute the allegation, and there was evidence suggesting possible retaliation between staff members. In another instance, two staff members overheard a resident screaming and making allegations of sexual abuse, but did not report the incident to administration as required. The allegations were later unsubstantiated, but the failure to report was confirmed through staff interviews. Additionally, the facility did not report an injury of unknown origin for a resident who sustained a left tibial fracture. The resident complained of leg pain, and imaging confirmed the fracture, but there was no documentation explaining how the injury occurred or if it was observed. The facility did not conduct or document an investigation into the cause of the injury, nor did it report the incident to the State Agency within the required timeframe. These failures were identified during a review of medical records and staff interviews, and were found to be evident for three residents reviewed for abuse allegations during the survey.