Failure to Timely Report Alleged Abuse, Neglect, and Injuries to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, to the State Agency as required. In multiple instances, incidents involving residents were not reported within the mandated timeframes. For example, an incident involving a resident who was struck by a family member, resulting in facial bruising, was not reported to the State Agency within two hours as required for events involving bodily injury. The facility became aware of the incident in the evening, but the report was not submitted until the following day. In another case, two residents were involved in a physical altercation after one resident entered the other's room. Although staff intervened and assessed both residents for injuries, and an incident report was completed, the event was not reported to the State Agency. Interviews with staff revealed a lack of clarity regarding the need to report resident-to-resident altercations as potential abuse or neglect, and the incident was only documented internally. Additionally, a resident who sustained a fall and was later found to have a right hip fracture did not have the incident reported to the State Agency within the required timeframe after x-ray results confirmed the injury. The x-ray findings were available to the facility, but the report to the State Agency was delayed. Staff interviews indicated that while internal notifications and assessments were performed, external reporting requirements were not consistently met. Facility policies required immediate reporting of such incidents, but these were not followed in the cited cases.