Late Submission of Abuse Investigation Results to OHCQ
Penalty
Summary
The facility failed to report the results of an investigation into an alleged resident-to-resident altercation that resulted in serious bodily injury to the Office of Health Care Quality (OHCQ) within the required 5 working days. Specifically, a resident reported being punched in the face and having their wheelchair overturned by another resident. Following the incident, the affected resident requested hospital evaluation and was found to have an acute fracture of the 5th metatarsal in the left foot. The initial incident report was submitted to OHCQ as required, but the follow-up investigation report was not submitted until more than 5 working days after the incident was identified. During the survey, discrepancies were found in the facility's documentation regarding the submission date of the follow-up report. Two versions of the follow-up investigation report were provided, each with different submission dates and times, and the facility was unable to provide an email confirmation of the submission as requested by the surveyor. Verification with OHCQ confirmed that the follow-up report was received late, beyond the regulatory timeframe. The Nursing Home Administrator and previous DON could not explain the inconsistencies in the documentation.