F0609

E

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

Delmar, Delaware Survey Completed on 12-05-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that staff immediately reported allegations of abuse and injuries of unknown origin to the Administrator/designee and that administrative staff timely reported these allegations to the state survey agency, as required by facility policy and federal and state law. The facility’s abuse policy required all alleged abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property to be reported immediately, but not later than two hours after the allegation is made (or within 24 hours if not involving abuse or serious bodily injury), to the Administrator and appropriate state officials. Despite this, multiple incidents involving several residents were not reported in accordance with these timelines.

One cognitively intact resident with major depressive disorder and anxiety alleged that a CNA intentionally pulled their arm while staff were applying a shoulder brace; an OT present acknowledged this as an allegation of abuse but did not report it, and the facility did not notify the state survey agency until the following day, beyond the required timeframe. Another resident with metabolic encephalopathy reported that a CNA had smacked their hand during care; the LPN who received the allegation did not immediately report it to the DON or manager on duty because she was unsure it constituted abuse and because the DON was occupied with another incident. In a separate incident, a resident with severe cognitive impairment reported that another cognitively impaired resident had hit a third cognitively impaired resident in the face, resulting in a busted and bleeding lip; staff, including the Activities Director and an LPN, became aware of the allegation on the day of the event, but the Administrator was not notified until two days later.

In another case, a resident with Alzheimer’s disease and senile degeneration of the brain, who was severely impaired in decision-making and dependent on staff for activities of daily living, was found with yellow fading bruises on the right upper arm and left thigh, and the resident could not explain how the bruising occurred. This injury of unknown origin was not reported to the state survey agency until several days after it was discovered, contrary to the Administrator’s stated expectation that such injuries be reported within two hours. Across these incidents, staff either delayed or failed to immediately report allegations of abuse or injuries of unknown origin to supervisory staff and the state survey agency, resulting in noncompliance with the facility’s own abuse reporting policy and regulatory reporting requirements.