Failure to Timely Report Abuse, Neglect, and Injuries to Authorities
Penalty
Summary
The facility failed to ensure that all allegations and incidents involving abuse, neglect, and misappropriation were reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency and law enforcement as required. Multiple incidents involving several residents were not reported within the mandated timeframe. In one case, a resident with severe cognitive impairment suffered a scalp laceration requiring 12 staples after a resident-to-resident altercation. The incident was not reported to law enforcement or the State Survey Agency until approximately nine hours after it occurred, despite staff and leadership being aware of the event and its severity. Interviews revealed that staff and administration were either unaware of the reporting requirements or did not consider the injury to be serious enough to warrant immediate reporting. Another incident involved a resident with severe dementia who experienced an unwitnessed fall resulting in a femur fracture. The fall was not reported to the State Survey Agency, as the facility determined internally that the incident did not meet the criteria for self-reporting, despite the resident's significant injury and cognitive impairment. The administrator stated that only incidents involving abuse or neglect were brought to his attention and that there was no specific policy for self-reporting incidents or accidents, relying instead on state guidelines. Additional deficiencies included a witnessed incident of verbal abuse by a cognitively intact resident toward another resident, which was documented in progress notes but not reported or investigated as potential abuse. Staff interviews indicated uncertainty about whether the incident qualified as abuse and whether it was reported to supervisors or the abuse coordinator. Another resident sustained an injury of unknown source after an unwitnessed fall, resulting in a femur fracture, but the incident was not reported as required. The facility's own policies and state regulations mandate immediate reporting of such incidents, but these were not followed in the cases reviewed.