Failure to Timely Report Suspected Abuse and Notify Ombudsman
Penalty
Summary
The facility failed to report suspected allegations of abuse within the required 24-hour time frame for two residents. One resident, who had diagnoses including dementia, cognitive decline, and major depressive disorder, was observed with a bruise of unknown origin on her right upper arm. The bruise was first noted in the morning, but the investigation and required notifications to the State Survey Agency were not initiated until two days later. Additionally, the facility did not notify the Long-Term Care Ombudsman (LTCO) about this incident as required by policy. Another resident, admitted with cellulitis and an ileostomy, reported that a CNA was verbally inappropriate, making a statement that was considered verbally abusive. The facility did not provide evidence that this allegation was reported to the LTCO. Interviews with facility staff, including the Infection Preventionist and the Administrator, confirmed that notifications to the LTCO were not made for either incident. The facility's policy requires prompt reporting of all abuse allegations, including injuries of unknown source, to both the State Survey Agency and the LTCO, but this was not followed in these cases.