Failure to Timely Report Alleged Abuse, Neglect, and Injuries
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation was made, as required by regulation and facility policy. In four separate cases, the facility did not report incidents involving major injuries or allegations of abuse within the required timeframe to the administrator and the State Survey Agency. These incidents included a resident with a coccyx fracture, a resident with a head laceration requiring staples after a fall, and a resident-to-resident altercation involving an allegation of being hit. In the first case, a resident with Alzheimer's disease and a history of falls was found to have a coccyx fracture after an X-ray ordered by hospice. The facility received the X-ray results indicating a likely acute fracture but did not report the incident to the appropriate authorities until two days later. In the second case, a resident with severe cognitive impairment and a history of unassisted transfers fell in the bathroom, resulting in a head injury that required five staples. The incident was not reported until the following day, outside the required reporting window. In the third case, a resident with minimal cognitive impairment alleged that her roommate hit her on the side of the face. The allegation was made to staff, but the facility did not report the incident to the authorities until two days later. Interviews with current administrative staff revealed that they were not employed at the time of the incidents and were unsure why the required reporting timelines were not met. Facility policy clearly states that all allegations of abuse, neglect, or injuries of unknown source must be reported immediately, but not later than two hours after the incident occurs or is suspected.