Failure to Timely Report and Investigate Injuries and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to timely report injuries of unknown origin and a resident-to-resident altercation to the state agency, as required by regulation and facility policy. In the case of one resident with severe cognitive impairment and a history of aggressive behaviors, two separate injuries of unknown origin were identified: a hand injury with a possible fracture and a significant hematoma to the forehead. In both instances, there was no documentation of a formal investigation, no staff interviews were conducted, and the incidents were not reported to the state agency within the required timeframe. The facility only filed a self-reported incident after the family raised concerns, and there was no evidence of staff education or training on abuse or injuries of unknown origin. Another resident, also with severe cognitive impairment and a history of falls, was found to have extensive bruising on the right shoulder, chest, and arm, as well as acute rib fractures and a clavicle fracture. Despite the presence of multiple injuries and the resident's inability to explain their origin, there was no documented investigation or timely reporting to the state agency. The facility's leadership was unaware of the incidents, and no self-reported incidents were filed for these events. Staff interviews and documentation required by facility policy were not completed. Additionally, a physical altercation occurred between two residents, resulting in a skin tear injury. The incident was documented in the medical record, but no self-reported incident was filed, and no investigation was conducted as required. Facility policy mandates that all alleged violations, including injuries of unknown origin and resident-to-resident altercations, be reported to the administrator and state agency within 24 hours and that thorough investigations with staff interviews and documentation be completed. These requirements were not met in the cases reviewed.