Failure to Report Suspected Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report alleged violations involving abuse and injury of unknown source for two residents, as required by both facility policy and federal and state law. For one resident with significant cognitive and physical impairments, a bruise and subsequent fracture of unknown origin were discovered after the resident had been discharged to the hospital. Multiple staff members and the resident's family observed the injury, but there was no clear documentation of how or when the injury occurred. Despite the facility's policy requiring immediate investigation and reporting of injuries of unknown source, the incident was not reported to the state agency, and the Director of Nursing and Administrator were uncertain about whether the injury had been reported at all. In the second case, a resident with severe cognitive impairment was struck on the chest by a visitor during an altercation witnessed by the facility's social worker. The social worker intervened and reported the incident to the Administrator and DON, but did not consider the event to be physical abuse and did not report it to the state agency. The care plan was updated to reflect the resident's family relationship dynamics, but there was no evidence of further action or restriction of visitation. The Administrator later stated that the incident was not reported because the resident denied feeling abused, despite the resident's documented severe cognitive impairment. Both incidents demonstrate a failure to follow facility policy and regulatory requirements for reporting suspected abuse, neglect, or injuries of unknown origin. The facility did not ensure that all alleged violations were promptly investigated and reported to the appropriate authorities, as required. Staff interviews revealed confusion and lack of clarity regarding reporting responsibilities, and documentation was inconsistent or incomplete regarding the injuries and the actions taken.