Failure to Report Resident’s Allegation of Injury During Care as Potential Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse reporting policy when a resident alleged injury during care. Resident 1, admitted in October 2025 with muscle weakness and gait and mobility abnormalities and documented moderate memory impairment on an MDS dated 11/5/25, reported to Licensed Nurse (LN) 1 that she had been injured while receiving care from facility staff and that she felt unsafe. LN 1 confirmed in an interview on 2/5/26 that he did not report this allegation to facility management. A progress note dated 11/5/25 documented that the resident reported recent trauma to both legs and feet from dangling off the bed, with a large area of bruising to the left lower leg and a 0.2 cm linear skin break on the lateral aspect of the left lower leg, and noted the resident’s preferences for using multiple staff members and gently moving her legs. Further record review showed that a hospital wound care record dated 11/6/25 documented the resident’s report that she was rolled by a CNA at the SNF and nearly fell out of bed, sustaining injuries to her left leg and right foot, and described discoloration on the plantar surface of the left foot possibly related to trauma. The resident’s care plan initiated on 11/6/25 identified impaired skin integrity related to trauma and risk for infection. The Director of Staff Development stated that staff are expected to immediately report new injuries to the nurse and that if a resident reports being injured during care with another staff member, the CNA is to report it as potential abuse. The DON stated that staff are expected to report any injury of unknown source or allegation of abuse to management and acknowledged that failure to report could result in residents potentially experiencing further abuse and injury. The facility’s abuse reporting and investigating policy, revised 9/22, requires that all reports of resident abuse, including injuries of unknown origin, be immediately reported to the administrator and appropriate officials within specified time frames, which did not occur in this case.
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