Failure to Timely Report Abuse, Neglect, and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report multiple allegations of abuse, neglect, and injuries of unknown origin to the state survey agency within the required timeframe, as outlined in their own policy and federal regulations. Several incidents involving resident-to-resident altercations, injuries of unknown origin, and alleged staff abuse were either not reported at all or were reported late. In some cases, staff and leadership were unclear about what constituted a reportable event, leading to delays or omissions in reporting. For example, altercations between residents, such as one resident attempting to dump another from a wheelchair or a resident grabbing another by the shirt collar, were not reported to the state agency as required. In other cases, injuries of unknown origin, such as a resident's acute wrist fracture, were reported more than two hours after discovery, contrary to policy requirements. The report details that staff, including LPNs, RNs, and DONs, sometimes failed to recognize or escalate incidents as reportable abuse or altercations. In several instances, staff deferred to corporate guidance before submitting reports, which contributed to delays. There were also communication breakdowns, with some administrators and regional staff not being informed of incidents in a timely manner. For example, after a resident was found with a new fracture, the DON waited for corporate input before reporting, resulting in a late submission. In another case, a DON instructed staff not to report a resident-to-resident altercation, classifying it as a behavioral issue instead, despite staff concerns that it met the criteria for abuse. Residents involved in these incidents often had significant cognitive impairments, dementia, or physical limitations, making them particularly vulnerable. The lack of timely reporting prevented prompt investigation and intervention, as required by both facility policy and regulatory standards. The facility's failure to consistently recognize, document, and report these events as abuse, neglect, or injuries of unknown origin led to noncompliance with reporting requirements and affected the safety and well-being of multiple residents.