Failure to Report Abuse, Neglect, Misappropriation, and Significant Injuries
Penalty
Summary
The facility failed to timely report incidents of suspected abuse, neglect, misappropriation, and falls with significant injury for five residents, as required. For one resident with moderate cognitive impairment and hemiplegia, a grievance was filed by a friend alleging staff yelled at and were rude to the resident, but there was no evidence that this allegation of abuse or neglect was reported to the appropriate authorities. Another resident, who was cognitively intact and had hypertension and PTSD, reported missing money, but the grievance was not completed or investigated, and there was no report of misappropriation made. A third resident with moderate cognitive impairment and supranuclear ophthalmoplegia experienced multiple falls, including two with head injuries, but these incidents were not reported to Residential Care Services (RCS) as required. Documentation showed injuries such as bumps, abrasions, and facial bruising, with neuro checks initiated, but no external reporting occurred. Similarly, another resident with moderate cognitive impairment and acute kidney failure sustained a fall resulting in a hematoma near the eyebrow, but this was not reported to RCS. Documentation included witness and nursing notes describing the incident and injury. A fifth resident with moderate cognitive impairment and lung cancer suffered a fall resulting in a deep laceration to the left lower extremity, requiring hospital transport. Despite the severity of the injury, there was no evidence that this incident was reported to RCS. Across all cases, review of facility logs and reported incidents confirmed that required reports for significant injuries, misappropriation, and abuse/neglect allegations were not made, and in some cases, investigations were incomplete or not conducted.