Failure to Report Suspected Abuse and Injuries of Unknown Origin
Penalty
Summary
This deficiency occurred when the facility failed to report suspected resident-to-resident abuse and injuries of unknown origin to the appropriate authorities, as required by both facility policy and state regulations. A resident with Alzheimer's disease, muscle weakness, anxiety, and adult failure to thrive, who was at risk for falls, experienced multiple injuries including a swollen and discolored right foot, facial bruising and swelling, a cut lip, and later, significant bruising and fractures to the right hand and hip. Documentation in the medical record and staff statements indicated that the resident reported being punched in the face and having her foot stomped on, and a CNA documented that the resident stated she had been hit by another resident. Despite these reports and visible injuries, the incidents were not reported to state agencies or law enforcement as required. The facility's internal investigation into the altercation between the two residents was limited. The administrator reviewed the incident and determined that no further investigation was warranted, and did not submit a Self-Reported Incident (SRI) to the state. Additionally, subsequent injuries to the resident's hand and hip were not reported or investigated as potential abuse or neglect. The facility's policy clearly required immediate notification of state officials and law enforcement in cases of suspected abuse or injury of unknown origin, but this protocol was not followed. Interviews with the administrator confirmed that the incidents were not reported because he did not consider them to be abuse, despite the resident's statements and physical injuries. The lack of reporting and investigation into these incidents resulted in non-compliance with regulatory requirements for timely reporting and investigation of suspected abuse, neglect, or injuries of unknown origin.