F0609

E

Failure to Timely Report Allegations of Abuse, Neglect, and Injuries of Unknown Origin

Hagerstown, Maryland Survey Completed on 01-29-2026

Penalty

Fine: $21,665

Summary

The deficiency involves the facility’s failure to timely report allegations of abuse, neglect, and injuries of unknown origin to the State Agency (SA) within required timeframes after staff became aware of them. For one incident, a resident reported to a GNA that someone had been in the room and touched the resident inappropriately at 6:45 AM. The on‑call Unit Manager acknowledged being aware of the allegation before 9:30 AM but did not notify the Nursing Home Administrator (NHA) until 9:30 AM, and the report to the SA was not sent until 10:47 AM. The NHA, who was involved in abuse investigations and review of final reports, could not explain the discrepancy between the time the allegation was known and the time it was reported to the SA.

In another incident, an injury of unknown origin involving discoloration and bruising to a resident’s right knee and shin was known to staff earlier than what was reported to the SA. A family member reported a bruise on the resident’s right knee on one evening, and an RN documented this in the progress notes the following day, which would have required reporting to the SA within 24 hours. However, the facility’s investigation file indicated that management did not recognize the injury of unknown origin until two days later in the morning, and the SA was not notified until late that morning. The RN involved stated she knew injuries of unknown origin should be reported to the NP and supervisor and that suspected abuse should be reported to the NHA within 2 hours, but she had no rationale for not reporting this injury when first made aware. The Corporate Clinical Resource Nurse confirmed the RN’s earlier awareness, and the NHA again could not explain the discrepancy in the reported awareness time.

Additional deficiencies occurred when staff failed to promptly report allegations of abuse and improper care involving other residents. In one case, a respiratory therapist was documented as having loud, aggressive interactions with a ventilator‑dependent resident, including statements about tying the resident down or sending the resident out, and a statement that patients who hit the therapist would be hit back. A GNA described the resident as anxious with arms up blocking the therapist, and the LPN on the unit acknowledged knowing the abuse policy and recognizing the behavior as inappropriate but only texted the unit manager hours later; the facility did not report the allegation to the SA until approximately five hours after the start of the therapist’s documented aggression. In another case, a resident reported pain and an inappropriate transfer by a GNA during a move to a bedside commode, and the resident’s daughter later called to reiterate the resident’s pain and allegation. Although the GNA was reassigned and management was notified, no further action was taken until two days later when the resident continued to voice concerns and left AMA, and the SA was not notified of the allegation until that same day, well beyond the required reporting timeframe. The NHA acknowledged understanding that this reporting was late.