Failure to Timely Report Suspected Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse and injuries of unknown origin for two residents. In the first case, a companion of a resident overheard a CNA speaking to the resident in a stern and demanding voice, telling the resident to stop crying and to pay attention, which caused the resident to become tearful, upset, and anxious. The companion observed the CNA yanking the resident's shirt off and reported the incident to the resident's daughter, who then notified the DON. Although the facility initiated an internal investigation and reported the incident to the state agency, they did not notify law enforcement as required by policy and federal regulations. In the second case, the facility was informed by a resident's wife of bruising and swelling of unknown origin on the resident's right foot. An X-ray revealed a fracture of the 5th metatarsal. The RN Supervisor did not notify the Nursing Home Administrator of the injury until three days after the incident, and the facility failed to report this significant injury of unknown origin to the State Agency within the required 24-hour timeframe. The facility's policy and federal requirements mandate immediate reporting of such incidents to both the state agency and law enforcement, especially when abuse or serious bodily injury is suspected. Both incidents involved residents with significant medical and cognitive impairments, including severe cognitive impairment, muscle weakness, and dependence on staff for activities of daily living. The facility's failure to follow established reporting protocols for suspected abuse and injuries of unknown origin resulted in noncompliance with federal and state regulations, as well as the facility's own policies.