Failure to Report Abuse Allegation and Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report allegations of verbal abuse and an injury of unknown origin to the state agency as required by policy. In the first incident, a resident with multiple medical conditions, including vascular dementia and an above-the-knee amputation, was involved in a verbal altercation with a CNA. The CNA was reported by another staff member to have yelled at and threatened the resident, which the resident later confirmed made him feel threatened and constituted verbal abuse. Although the incident was reported to the Unit Manager Nurse (UMN) by the witnessing CNA, the UMN did not escalate the report to the Director of Nursing (DON) or the Administrator, and no Self-Reported Incident (SRI) was filed with the state agency. In the second incident, another resident with diagnoses including heart failure, renal insufficiency, and COPD, suffered a fall and subsequent leg fracture while being transported by an outside service. The resident described the transport driver slamming on the brakes, causing her to slide out of her wheelchair and sustain the injury. The facility was notified by the hospital of the incident and received hospital records indicating the injury occurred during a motor vehicle accident. Despite this, the DON did not report the injury to the state agency, relying solely on the hospital's account of the event. Both incidents were not reported to the state agency as required by the facility's policy on abuse, neglect, exploitation, and injuries of unknown source. The failure to report affected two of three residents reviewed for abuse reporting, despite clear internal and external notifications of the incidents and the facility's own policy mandating immediate reporting.