Failure to Investigate and Report Alleged Abuse and Injuries of Unknown Source
Penalty
Summary
The facility failed to thoroughly investigate and report two separate incidents involving allegations of abuse and injury, as required by state law and facility policy. In the first incident, a female resident with a history of mood disorders and dementia verbally abused another resident in the dining room, using derogatory language and following the other resident around. The event was documented in a progress note by an LVN, but there was no evidence of an incident report or notification to the State Survey Agency. Interviews with staff revealed uncertainty about whether the incident was reported or investigated, and the Director of Nursing was unaware of the event. In the second incident, a male resident with severe cognitive impairment and a history of falls was found on the floor in another resident's room, complaining of back pain. Although initially assessed as having no major injury, the resident later complained of leg pain and was diagnosed at the hospital with a fracture in the left hip. The incident was documented as an unwitnessed fall, and the administrator considered it an explainable injury. However, there was no evidence that the injury, which met the criteria for an "injury of unknown source" per state guidance, was investigated or reported as required. Both incidents demonstrate a lack of adherence to facility policy and state regulations regarding the investigation and reporting of abuse, neglect, and injuries of unknown source. The facility did not ensure that all allegations were thoroughly investigated, nor did it report the results to the administrator or appropriate authorities within the required timeframe.