Failure to Timely Report Suspected Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin, were reported immediately, but no later than two hours after the allegation was made, as required. Specifically, a resident with severe cognitive impairment and multiple comorbidities, including dementia, hypertensive heart disease, and chronic kidney disease, was found to have a significant bruise and swelling to her right thumb of unknown origin. The injury was first noted during a change of condition skin assessment, and there was no documentation indicating how the injury occurred. Interviews and record reviews revealed that the resident was dependent on staff for all self-care and mobility, requiring a wheelchair and comprehensive assistance. On the morning of the incident, the resident reported that two CNAs entered her room, and one of them pulled her thumb backward, causing her to scream in pain. A roommate corroborated hearing the resident cry out, though the curtain was drawn, preventing visual confirmation. The injury was later observed by another CNA, who reported it to a nurse, and the resident was subsequently transferred to a hospital for further evaluation. Despite the severity and unknown origin of the injury, the facility did not report the incident to the appropriate state authorities within the required timeframe. The incident was reported to Texas Health and Human Services via email more than 24 hours after the injury was first identified. The facility's own policy requires immediate reporting of suspected abuse, neglect, or mistreatment, but this protocol was not followed in this case.