Failure to Report and Investigate Injury of Unknown Origin in Resident with Recent Abuse Allegation
Penalty
Summary
The facility failed to report to the state survey agency an allegation of injury of unknown origin in a vulnerable area for a resident with a recent history of alleging sexual assault. The resident, who had moderate cognitive impairment and required substantial to maximum assistance with toileting, was found to have a new skin tear around her left labia, as documented in a nursing progress note. There was no further documentation regarding this injury, and no investigation was initiated or reported to the appropriate authorities. Interviews with facility staff revealed that the former DON was unaware of the injury and stated it should have been reported and investigated, especially given the resident's recent allegation of sexual assault. The LPN/Nurse Manager acknowledged being notified of the injury but did not report or investigate it. The Administrator also confirmed that this was the first time they were made aware of the incident and that it should have been reported and investigated. No investigation was conducted, and the incident was not reported to the state survey agency.