Failure to Timely Report and Investigate Abuse, Neglect, and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to implement policies and procedures for reporting and investigating abuse, neglect, and injuries of unknown origin (IUO) for multiple residents. In several cases, staff did not report IUOs to the state agency within the required timeframe, and documentation of final investigative reports was missing or incomplete. For example, one resident with severe cognitive impairment was found with a large bruise on her hand, and although staff notified the physician and responsible party, the injury was not reported to the state agency as an IUO until several days later. Staff interviews confirmed that the policy required reporting within two hours, but this was not followed. Another resident was discovered with significant bruising and was unable to recall any injury or trauma. The incident was not reported to the state agency until several days after discovery, and staff statements indicated a lack of immediate notification to management as required by policy. Additionally, for a resident with an allegation of neglect, there was no evidence that the final investigative report was sent to the state agency within the required five-day period. Staff interviews confirmed knowledge of the reporting requirements but acknowledged the failure to submit the necessary documentation. A further case involved a resident with severe cognitive impairment who was found with an old bruise of unknown origin. The incident was not reported to the state agency within the required two-hour window, and documentation of the report was incomplete. Staff interviews consistently indicated awareness of the facility's abuse and IUO reporting policies, including the need for immediate reporting and investigation, but these procedures were not consistently followed for the residents involved.