Failure to Timely Report Suspected Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment—including injuries of unknown source and misappropriation of resident property—were reported immediately, but not later than two hours after the allegation was made, to the administrator and to other officials, including the State Survey Agency, as required by state law. This deficiency was identified for two residents reviewed for abuse and neglect. In one case, a resident with severe cognitive impairment and multiple comorbidities, including dementia and diabetes, was found to have scattered bruising of different colors and a fractured arm. The injury was not reported to the state agency or the abuse coordinator in a timely manner, despite the presence of significant bruising and a fracture of unknown origin. Staff interviews revealed confusion about the timing and reporting of the injury, with some staff believing the injury was older than it appeared and others unsure of who had been notified. Documentation showed that the injury was not immediately recognized or reported, and the cause of the injury remained unclear. In another instance, an allegation of abuse involving a staff member slapping a resident on the cheek was not reported to the administrator or the state agency within the required two-hour timeframe. The incident was reported 15 hours after it occurred. Staff interviews indicated a lack of clarity regarding the appropriate method and urgency of reporting such incidents, with some staff relying on text messages rather than direct phone calls to notify management. The facility's own policy required immediate reporting of suspected abuse, neglect, or injury of unknown origin, but this was not followed in practice. Both failures were substantiated by record reviews, staff interviews, and review of facility policies. The lack of timely reporting of these incidents could place residents at risk for abuse or neglect and could lead to a diminished quality of life, as stated in the report. The findings highlight lapses in communication, documentation, and adherence to established procedures for reporting suspected abuse and significant injuries.