Failure to Report Suspected Abuse to Law Enforcement
Penalty
Summary
Facility staff failed to immediately report an allegation of suspected resident abuse to local law enforcement after a resident was found to have a fractured left humerus. On 02/03/26, the Office of Health Care Quality (OHCQ) received a facility-reported incident concerning this resident’s injury, which was reported by the facility as an injury of unknown source. A subsequent 5-day follow-up investigation by the facility, reviewed on 03/03/26, documented that an x-ray confirmed the left humerus fracture, that there were no witnesses to the incident, and that the resident was unable to tell staff how the injury occurred. The facility’s investigation concluded that the cause of the injury was inconclusive and that abuse had been ruled out. During the investigation, the facility measured the resident’s Brief Interview for Mental Status (BIMS) and recorded a score of 13/15, while noting that the resident’s BIMS score fluctuates. A review of the facility’s abuse policy on 03/05/26 showed that the facility designates an Abuse Prevention Coordinator responsible for reporting allegations or suspected abuse, neglect, or exploitation to the State Survey Agency and other officials in accordance with State law. Despite this policy and the requirement that allegations of abuse be reported to both OHCQ and local police in a timely manner, the 5-day follow-up investigation indicated that the allegation was not reported to law enforcement. In an interview on 03/11/26 during the exit conference, the administrator and DON confirmed that law enforcement had not been notified of the allegation related to the resident’s fractured humerus.
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