Failure to Timely Report Abuse, Neglect, Elopement, and Injuries
Penalty
Summary
Surveyors identified that the facility failed to immediately report, within the required two-hour timeframe, multiple alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and elopement to the State Survey Agency. In several cases, incidents involving sexual contact between cognitively impaired residents were not reported or investigated, despite both residents having severe cognitive impairment as indicated by low BIMS and SLUMS scores. Staff and administration assumed the interactions were consensual, even though the residents' cognitive status called their ability to consent into question. Additionally, an incident involving a resident being found undressed with another resident, and another case where a resident was found in another's bed, were not reported or investigated as potential abuse or sexual assault. The facility also failed to report multiple incidents of resident elopement. Several residents with severe cognitive impairment and a history of wandering or elopement were able to leave the facility grounds unsupervised, sometimes by climbing or breaking through fences. In some cases, residents were found by staff or police outside the facility, and in one instance, a resident sustained a skin tear during an elopement. These incidents were not reported to the State Survey Agency as required, and in some cases, the administration was unaware of the reporting requirements for elopement events. Additional deficiencies included failure to report injuries of unknown origin and incidents during transportation. One resident with severe cognitive impairment was observed with a large bruise to the eye, and the cause could not be determined, but the incident was not reported for investigation. Another resident fell out of a wheelchair during transport due to improper securing, resulting in a head abrasion, and this incident was reported late. In all these cases, the facility did not follow required protocols for timely reporting and investigation of potential abuse, neglect, or injury, as confirmed by staff and administrative interviews and record reviews.