Failure to Report Alleged Abuse and Injury of Unknown Source
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of possible abuse or mistreatment to the State Survey Agency as required by regulation and by its own Abuse Prevention Program policy. The policy states that any allegation of abuse or any incident resulting in serious bodily injury must be reported to required regulatory agencies immediately, but not more than two hours after the allegation, and that other reportable incidents must be reported within 24 hours. Despite this, the facility did not report an incident in which a resident developed new rib fractures associated with staff repositioning, nor did it report subsequent concerns raised by the resident’s representative that the CNA had been angry and aggressive during care. The resident involved had multiple significant comorbidities, including a left pelvic fracture, chronic respiratory failure, severe protein-calorie malnutrition, muscle weakness, dysphagia, sacral pressure ulcer, GERD, repeated falls, osteoporosis, and a history of multiple fractures, including rib fractures. The care plan and physician orders required Q2–3 hour repositioning with a wedge and assistance of one staff for bed mobility and transfers. On the date of the incident, while being repositioned in bed by a CNA, the resident complained of severe sharp, stabbing pain in the left ribs, with pain on palpation. A nurse assessed the resident, administered PRN Tramadol without effective relief, and the resident was sent to the ER, where imaging showed suspected new fractures of the left 7th and 8th anterior ribs along with old bilateral rib fractures and thoracic compression fractures. Following the incident, the resident’s representative reported to facility leadership that the CNA had entered the room extremely agitated and aggressive about the call light, and that the CNA allegedly grabbed the resident around the torso from behind and yanked her backward in bed, which the representative believed caused the rib fractures. The representative also reported these concerns to the State Survey Agency. The DON acknowledged speaking with the CNA, who reported hearing a “crack” while repositioning the resident, and acknowledged speaking with the representative, who questioned how the fractures could have occurred when repositioning had been done many times previously without incident. The DON and Administrator stated they did not initiate an abuse investigation or report the incident to the State Survey Agency because, based on the resident’s history of fractures and comorbidities, they did not consider the event or the representative’s concerns to be an allegation of abuse or neglect, and as of survey exit the facility could not provide additional information explaining why the potential mistreatment was not reported.
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