Failure to Timely Report and Thoroughly Investigate Alleged Abuse and Unexplained Bruising
Penalty
Summary
The facility failed to ensure that an alleged violation involving abuse was thoroughly investigated and reported in a timely manner for one resident. Facility policy on Abuse, Neglect, Exploitation required that all bruises, skin tears, and other found injuries be investigated for potential abuse and that reasonable suspicion of a crime against a resident be reported within 2 hours if serious bodily injury was involved and within 24 hours if not. On December 24, 2025, at 9:00 PM, a NA reported that the resident had a 10 cm x 6 cm red/purple bruise with some swelling on the left forearm near the elbow. When asked how it happened, the resident stated "him" and said she did not want him to ever touch her again. The only person notified per the incident report was the resident’s daughter at 10:20 PM that night; there was no documentation that the provider or appropriate authorities were notified as required by policy and regulation. An Interview/Statement Form completed by the NA on December 24, 2025, at 10:00 PM documented that he noticed the mark while getting the resident ready for bed and that she became restless and tossing and turning during care. A later interview on December 26, 2025, documented the NA’s account that the resident had been wheeling herself around the unit, exit seeking, and pulling herself by the wall prior to care, and that he noticed the bruise only after changing her and returning her to the chair. Additional interviews on December 26, 2025, with another NA and an LPN indicated that the bruise was not observed earlier on December 24, and that on December 25 the resident wore long sleeves and went on LOA with family. On December 26, 2025, the resident told staff that a "big fat white guy" had been rough and mean to her the previous day. The NHA documented the concern as a grievance on December 26, 2025, and later stated that administration decided not to report the incident as abuse and could not determine whether the provider had been notified, demonstrating that the allegation was neither promptly reported nor thoroughly investigated in accordance with policy and regulatory requirements.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.