Failure to Timely Report Alleged Abuse, Neglect, and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure timely reporting of alleged violations involving abuse, neglect, or mistreatment to the State Survey Agency as required by regulation. Specifically, the facility did not report within the mandated two-hour timeframe when a resident sustained a serious bodily injury, nor did it report multiple resident-to-resident altercations and unwitnessed injuries within the required period. For example, one resident experienced a fall resulting in an acute distal fibular diametaphyseal fracture, but the incident was not reported to the state until after a second x-ray confirmed the injury, despite the initial x-ray already indicating a fracture. Additionally, the facility did not report two separate resident-to-resident altercations involving physical contact and aggression. In one instance, two residents engaged in a physical altercation where one struck the other, causing the second resident to stumble and then push back. These incidents were documented in progress notes and care plans, but there was no evidence that they were reported to the State Survey Agency as required. Furthermore, the facility failed to report several unwitnessed injuries and falls, including bruising, skin tears, and bumps to the head, for another resident who had a history of behavioral disturbances and unexplained injuries. Interviews with staff, including LVNs, the DON, and the Administrator, revealed inconsistent understanding and application of reporting requirements. Staff often waited for confirmation from a nurse practitioner or physician before reporting injuries, even when initial evidence suggested a serious injury had occurred. The facility's own policy required immediate reporting of all alleged violations, including those involving resident-to-resident altercations and injuries of unknown origin, but these procedures were not consistently followed.