Failure to Timely Report Allegations of Mistreatment and Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure timely notification to the State Agency upon learning of allegations of mistreatment and injuries of unknown origin for two residents. In the first case, a resident with heart failure and on dual antiplatelet therapy was found to have a large, discolored bruise on the back of the left upper arm. The resident reported to staff that a night aide had been rough during weighing, but could not identify the individual. Despite this allegation and the presence of a significant bruise, the incident report was not completed until two days after the event, and the State Agency was not notified as required. The Assistant Director of Nursing (ADNS) cited lack of access to the online reporting system as a reason for not reporting, and the Director of Nursing (DNS) stated she did not report because the resident later denied intentional harm. In the second case, another resident with severe cognitive impairment and contractures was found to have bilateral bruising under the arms, including marks resembling fingerprints and a handprint. The resident was unable to explain the cause of the bruising. Staff updated the care plan to require two staff for transfers and sent home tight clothing, but did not initiate or document a full investigation. The incident report indicated no investigation was initiated, and the State Agency was not notified of the injury of unknown origin. The DNS believed the bruising was due to tight clothing and did not consider it reportable after her own investigation, and did not consult the State Agency for clarification. Facility policy and state regulations require immediate reporting of all alleged violations, including abuse or injuries of unknown origin, to the State Agency within two hours. Both cases demonstrated a failure to follow these requirements, as allegations and significant injuries were either not reported or reported late, and documentation was incomplete or not included in official records. Staff interviews confirmed a lack of understanding or access to the reporting system, and incident reports were sometimes kept in personal files rather than official facility records.