Failure to Timely Report Suspected Abuse/Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to timely report an alleged incident of abuse/neglect within the required 2-hour timeframe. An incident report filed on 02/03/2026 at 4:00 PM documented an event as occurring on 02/03/2026, but further review showed the incident actually occurred on 01/30/2026. The event involved Resident #1, described as a vulnerable adult with cognitive impairment, who was found with her face pressed against the side rails of her bed on 01/30/2026, sustaining puncture wounds to the outside of her cheek that required sutures and a transfer to a local hospital. Although the report indicated the Administrator was notified on 02/03/2026, the Administrator was already aware of the incident that occurred on 01/30/2026. The incident was not reported to the appropriate authorities until after an Adult Protective Services investigator arrived at the facility on 02/03/2026 at 4:00 PM to investigate the allegation. During an interview on 02/09/2026, the facility Risk Manager stated she decided to report the incident after the APS investigator entered the facility and confirmed that her expectation is that any suspected abuse observed by staff must be reported immediately so she can initiate an investigation. She also stated that any injury of unknown origin must be reported within two hours, followed by a five-day report with investigation findings. The facility’s written policy on Abuse, Exploitation or Misappropriation-Reporting and Investigating, last revised 04/2021, requires that suspected abuse, neglect, or injury of unknown source be reported immediately to the administrator and other officials, defining “immediately” as within two hours for allegations involving abuse or resulting in serious bodily injury. The Risk Manager did not provide an explanation for the delay in reporting this incident, resulting in noncompliance with the facility’s policy and regulatory reporting timeframes.
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