Failure to Timely Report Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report allegations of abuse and injuries of unknown origin to the state survey agency within the required timeframes for three residents. According to facility policy, all alleged violations involving abuse or serious bodily injury must be reported immediately, but not later than two hours after the allegation is made. In the case of one resident with severe cognitive impairment and a history of behavioral issues, a CNA witnessed an LPN strike and verbally abuse the resident during care. The CNA delayed reporting the incident until after her shift, and the RN Supervisor also waited until the LPN had left the building before notifying the DON. The DON subsequently reported the incident to the state agency over four hours after the alleged abuse occurred. Another resident, who had intact cognition and a history of a recent hip fracture, was found to have a dislocated femur following a routine X-ray. The injury was of unknown origin, and the resident denied any trauma or falls. The injury was not reported to the state survey agency until 26 hours after it was identified, despite facility expectations that such incidents be reported immediately to allow for prompt investigation. The LPN responsible for reporting could not explain the delay. A third incident involved an altercation between two residents, where one resident entered another's room and pulled their hair. Staff intervened and separated the residents, and law enforcement and responsible parties were notified. However, the incident was not reported to the state survey agency until more than three hours after it occurred. Interviews with facility leadership confirmed that these reports were not made within the required timeframes, as outlined in facility policy.