Failure to Timely Report Allegations of Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to timely report allegations of physical and verbal abuse, as well as injuries of unknown origin, to the State Survey Agency as required. For one resident with severe cognitive impairment and multiple medical conditions, an incident occurred where the resident was found with a bleeding nose and alleged being punched. Although an assessment and room change were completed, no Self-Reported Incident (SRI) was filed for this physical abuse allegation. Additionally, when the same resident was later found with facial bruising, skin tears, and injuries of unknown origin, no SRI was submitted for this event either. The Administrator confirmed that these incidents were not reported until approximately eight months later, following discussion during the survey. Another resident with moderately impaired cognition and multiple diagnoses was subjected to verbal abuse by another resident, which resulted in emotional distress. The SRI for this incident was filed three days after the event, rather than within the required timeframe. A subsequent incident of verbal abuse by the same resident was not reported at all. The facility's policy requires that allegations of abuse or serious injury be reported to state or federal agencies within two hours, and all other allegations within 24 hours, but these requirements were not met in the cases reviewed.