Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that all allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately to the State Survey Agency as required. Specifically, when a resident alleged that an LVN squeezed her left hand, resulting in bruising, the facility did not report this allegation to the State Survey Agency within the mandated two-hour timeframe. The incident was documented by staff, and the resident demonstrated and described the alleged abuse, with staff noting that the bruises appeared consistent with fingerprints. Despite this, the facility did not treat the allegation as reportable abuse at the time. The resident involved had a complex medical history, including venous insufficiency, generalized anxiety disorder, delusional disorders, muscle wasting and atrophy, muscle weakness, and heart failure. She was noted to have aggressive behaviors, including attempts to hit staff, verbal aggression, and refusal of care and medications. On the day of the incident, staff observed multiple bruises on her left hand, and the resident reported pain and described her hand being squeezed by a nurse. Staff notified supervisors and the DON, and an x-ray was ordered, but the incident was not reported to the State Survey Agency as an abuse allegation within the required timeframe. Interviews with staff revealed confusion and disagreement about whether the incident constituted abuse and whether it should have been reported. The DON and Administrator reviewed the situation and determined, based on documentation of the resident's combative behavior, that the bruising could be explained by the resident's actions rather than abuse. As a result, the alleged perpetrator was not suspended, and the incident was not reported as required by facility policy and regulation. The facility's own policies require immediate reporting of all abuse allegations, but this process was not followed in this case.