Failure to Timely Report Alleged Abuse and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to timely report and complete required investigations for alleged abuse and injuries of unknown origin for two residents. For one resident (R1), who had respiratory failure, heart failure, bone cancer, and pleural effusion and was dependent on staff for eating, bed mobility, transfers, and toileting, staff discovered a large dark purple bruise on the left ribs extending from the armpit into the ribcage. This injury of unknown origin was considered a potential abuse situation that required reporting to the State Agency within two hours and submission of a final misconduct incident report with investigation findings within five business days. The self-report showed the final report was not submitted until several months later, well beyond the 5‑day requirement. The facility’s own policy required immediate reporting of any suspicion of abuse, neglect, exploitation, misappropriation, or suspicious bruising to the Administrator or designee to ensure all alleged violations, including injuries of unknown source, were reported. The facility also failed to report an allegation of sexual abuse involving another resident (R2), who had pneumonia, stroke, Lewy Body dementia, hallucinations, amnesia, and cognitive communication deficit but was cognitively intact per MDS and largely independent or needing only supervision for mobility and toileting. R2 accused an RN of trying to have sex with them, and this allegation was documented in the facility’s grievance records. However, surveyor review found no evidence that this allegation was reported to the State Agency within two hours or at all, and no misconduct incident report with investigation findings was submitted within five business days. During interviews, the social worker stated they believed reporting was unnecessary because the investigation was completed quickly, the resident had Lewy Body dementia, and the police did not substantiate the allegation. The Nursing Home Administrator confirmed that both incidents should have been reported within two hours with final reports submitted within five days and acknowledged that one report was extremely late and the other was never reported.
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